TH 


jjMiACTICAL  AND  SYSTEMATIC 


TREATISE 


FRACTURES  AND  DISLOCATION? 


BT 


A.  J.  HOWE,  A.  M.,  M.  D. 

PROFESSOR  OF   SURGERY    IX   THK   ECLECTIC  MEDICAL  INSTITUTE. 
FOURTH    EDITION. 


CINCINNATI: 

JOHN    M.    SCUDDERS 

1891. 


,  I 

IHT/;SO?TL*0    nO  3D:  /-] 

;"      'HI 


Entered  According  to  Act  of  Congress  in  1870,  by  JOHN  M.  SCTJDDER,  in  the  Clerk's  oflio* 
of  the  District  Court  for  the  Southern  District  of  Ohio. 


CONTENTS. 


PART  I.    FRACTURES. 

PAGE. 

PREFACE 11 

CHAPTER  I. 
General  Observations  upon  the  Nature  and  Treatment  of  Fractures...    17 

CHAPTER  II. 
Signs  of  Fracture 22 

CHAPTER  III. 
Process  of  Union 29 

CHAPTER  IV. 
Non-union,  or  False-joint  after  Fracture 36 

CHAPTER  V. 
Defective  Union ~ 41 

CHAPTER  VI. 
General  Remarks  in  Regard  to  the  Treatment  of  Fractures 43 

CHAPTER  VII. 

Reduction  of  Displaced  Fragments 49 

CHAPTER  VIII. 
Apparatus  for  the  Treatment  of  Fractures 52 

CHAPTER  IX. 
Re-dressings 64 

CHAPTER  X. 

Movements  allowed  a  Patient. 66 

CHAPTER  XI. 
Management  of  Compound  Fractures 67 

CHAPTER  XII. 
Diastasis,  or  Separation  of  an  Epiphysis 72 

CHAPTER  XIII. 
Fracture  of  the  Cranium 74 

CHAPTER  XIV. 
Fracture  of  the  Inferior  Maxillary 80 

CHAPTER  XV. 
Fracture  of  the  Hyoid  Bone  and  Laryngeal  Cartilages 88 

CHAPTER  XVI. 

Fracture  of  the  Vertebrae..- 91 

(iii) 


iy  CONTENTS. 

PAQ«, 

CHAPTER  XVII. 
Fracture  of  the  Ribs  and  Costal  Cartilages 95 

CHAPTER  XVIII. 

Fracture  of  the  Clavicle 104 

CHAPTER  XIX. 

Fracture  of  the  Scapula 110 

CHAPTER  XX. 

Fracture  of  the  Humerus .. 117 

CHAPTER  XXI. 
Fracture  of  the  Ulna 137 

CHAPTER  XXII. 
Fracture  of  the  Radius 145 

CHAPTER  XXIII. 
Fracture  of  the  Bones  of  the  Hand 161 

CHAPTER  XXIV. 
Fracture  of  the  Pelvic  Bones 165 

CHAPTER  XXV. 
Fracture  of  the  Femur 171 

CHAPTER  XXVI. 
Fracture  of  the  Patella 215 

CHAPTER  XXVII. 
Fracture  of  the  Leg 221 

CHAPTER  XXVIII. 
Fracture  of  the  Bones  of  the  Foot ~ 249 


PAKT  Ii:    DISLOCATIONS, 


CHAPTER  I. 
General  Considerations : 225 

CHAPTER  II. 
Dislocation  of  the  Jaw 290 

CHAPTER  III. 
Dislocation  of  the  Vertebrae 297 

CHAPTER  IV. 
Dislocation  of  the  Ribs 303 

CHAPTER  V. 
Dislocation  of  the  Clavicle 305 

CHAPTER  VI. 
Dislocation  of  the  Scapula 310 

CHAPTER  VII. 
Dislocation  of  the  Humerus 314 


CONTENTS.  7 

PAGE. 

CHAPTER  VIII. 
Dislocation  of  the  Radius  and  Ulna  at  the  Elbow 335 

CHAPTER  IX. 
Dislocation  of  the  Wrist 349 

CHAPTER  X. 
Dislocation  of  the  Phalanges .T. 355 

CHAPTER  XI. 
Dislocation  of  the  Femur 359 

CHAPTER  XII. 
Dislocation  of  the  Patella 388 

CHAPTER  XIII. 
Dislocation  of  the  Tibia 391 

CHAPTER  XIV. 

Dislocation  of  the  Tibio-fibular  Articulations 397 

CHAPTER  XV. 
Dislocation  of  the  Ankle 399 

CHAPTER  XVI. 
Dislocation  of  the  Bones  of  the  Foot ,  ..  400 


ILLUSTRATIONS. 


FRACTURES. 

riGCEJE.  PAGE, 

1.  Partial  or  "green-stick"  fracture 27 

2.  Specimen  of  broken  ribs *. 33 

3.  Method  of  union  when  fragments  overlap 35 

4.  Brainard's  perforator  or  drill 39 

5.  Method  of  making  a  "  reverse  "  in  a  spiral  reversed  bandage 53 

6.  Bandage  of  strips 55 

7.  Lined  splint  material 58 

8.  Moulded  gutta-percha  splints 58 

9.  Carved  wooden  splints 58 

10.  "Wire  breeches".   59 

11.  Adhesive  strips  to  make  fast  to  the  leg,  for  purposes  of  extension.    60 
12..  Double  inclined  plane  fracture  box «  61 

13.  Welch's  double  inclined  apparatus. 62 

14.  Burge's  fracture  bed 63 

15.  Compound  fracture  of  the  leg. 67 

lb'.  Separation  of  the  lower  epiphysis  of  the  humerus 73 

17.  Fracture  of  the  lower  jaw 80 

18.  Pasteboard  splint  for  moulding  to  the  chin 84 

19.  Moulded  pasteboard  splint  for  the  chin 84 

20.  Dressing  for  fracture  of  the  inferior  maxillary 84 

21.  Application  of  silver  wire  to  adjacent  teeth 85 

22.  Fractured  rib 69 

23.  Union  of  broken  ribs 100 

24.  Fracture  of  the  Sternum 102 

25.  Fracture  of  the  Clavicle 105 

26.  Deformity  after  fracture  of  the  clavicle 107 

27.  Posterior  view  of  Fox's  dressing  for  fracture  of  the  clavicle 108 

28.  Anterior  view  of  Fox's  dressing  for  fracture  of  the  clavicle 108 

29.  Fracture  of  the  shoulder  blade Ill 

30.  Fracture  of  the  acromion 112 

31.  Fracture  of  the  coracoid  process 113 

32.  Fracture  of  the  neck  of  the  scapula 114 

33.  Huuierus,  divided  into  thirds 117 

34.  Carved  and  hinged  splint  for  the  shoulder. 119 

35.  Fracture  of  the  surgical  neck  of  the  humerus 120 

3G.  Woven  wire  splint  for  fractures  about  the  shoulder 121 

(Vll) 


viii  IIIUSTRATIONS. 

TIOCBE.  PAGE. 

37.  Fracture  of  the  shaft  of  the  humerus... 123 

38.  Dressing  for  fracture  of  the  shaft  of  the  humerus 124 

39.  Diastasis,  or  separation  of  the  lower  epiphysis  of  the  humerus...  120 

40.  Double  fracture  of  the  humerus 120 

41.  Deformity  after  fracture  of  the  humerus 128 

42.  Fracture  of  the  epitrochlea 129 

43.  Fracture  of  the  external  condyle  of  the  humerus 129 

44.  Fracture  of  both  condyles  of  the  humerus 129 

45.  Fracture  of  the  internal  condyle  of  the  humerus 130 

46.  Dressing  for  fractures  of  the  condyles  of  the  humerus. 131 

47.  Fracture  of  the  olecranon  and  coronoid  processes  of  the  ulna 137 

48.  Dressing  for  fracture  of  the  olecranon 138 

49.  Fracture  of  the  shaft  of  the  ulna 1 142 

50.  Fracture  through  upper  extremity  of  the  radius 147 

51.  Shows  action  of  rotating  muscles  o£  forearm 148 

52.  Fracture  through  middle  of  the  shaft  of  the  radius 148 

53.  Union  of  radius  and  ulna  after  fracture 149 

54.  Barton's  fracture  of  the  radius 150 

55.  "  Silver  fork  "  appearance  of  the  arm  after  Colics'  fracture  of  the 

radius 151 

56.  Colics'  fracture  of  the  radius 152 

57.  Splints  and  dressing  for  treatment  in  Colics'  fracture  of  the  radius.  155 

58.  Single  splint  for  treating  Colics'  fracture  of  the  radius 150 

59.  Fracture  of  both  bones  of  the  arm 157 

60.  Comminuted  fracture  of  both  bones  of  forearm , 158 

61.  Dressing  for  fracture  of  the  bones  of  the  forearm 159 

62.  Fracture  of  the  bones  of  the  hand 1(12 

63.  Fracture  of  a  phalanx  of  the  finger 103 

64.  Fracture  of  the  os  innominatum ]00 

64.  Section  of  the  head  and  neck  of  femur. 173 

65.  Fracture  of  the  neck  of  the  femur  within  the  capsule 179 

66.  Consolidation  after  fracture  of  neck  of  the  femur 1H) 

67.  Ligamentous  union  after  fracture  of  the  neck  of  the  femur 181 

68.  Excess  of  callus  after  extra-capsular  fracture  of  the  femur 1>2 

69.  Bony  union  after  fracture  of  the  neck  of  the  femur 1s  I 

70.  Fracture  of  the  greater  trochanter  at  its  extremity 1>5 

71.  Fracture  of  the  cervix  femoris  and  greater  trochanter ]85 

72.  Fracture  of  the  trochanter  major l>ii 

7.'!.  "  Wire  breeches"  applied 188 

74.  Fracture  of  the  shaft  of  the'femur 192 

75.  Straight  splint  in  the  treatment  of  fractures  of  the  femur 195 

76.  Extension  obtained  by  means  of  adhesive  strips 197 

77.  Dressing  for  fractures  of  the  femur 198 

78.  Union  of  fragments  of  femur  with  overlapping 199 

79.  Weight  and  pulley  tor  making  extension 199 

80.  Barges' fracture  apparatus  applied -(l" 

81.  Fracture  of  the  upper  third  of  the  femur 2<>1 

82.  Fracture  of  the  lower  third  of  the  femur 2<>7 

83.  Fracture  of  the  femur  just  above  the  condyles 2US 


ILLUSTRATIONS.  ix 

PAO« 

84.  Fracture  of  the  internal  condyle  of  the  femur 212 

85.  Fracture  of  both  condyles  of  the  femur 212 

86.  Wire  appliance  for  treating  fractures  near  the  knee 213 

87.  Fracture  of  the  patella 216 

88.  Ligamentous  union  after  fracture  of  the  patella 218 

89.  Dressing  for  fracture  of  the  patella 219 

90.  Fracture  of  both  bones  of  the  leg 222 

91.  Fracture  of  both  bones  of  the  leg  at  the  same  point 223 

92     Fracture  of  both  bones  of  the  leg  near  the  ankle 225 

93.  Handkerchief  hitch  just  above  the  ankle,  for  making  extension.  229 

94.  Gaiter  appliance  to  the  ankle,  for  making  extension 229 

95.  Adhesive  strip  fastening  to  the  leg,  for  making  extension 230 

96.  Dressing  for  fracture  of  both  bones  of  the  leg 230 

97.  Fracture  box,  for  treating  the  leg  after  both  bones  are  broken....  231 

98.  Fracture  of  both  bones  of  the  leg,  showing  consolidation  of 

fragments 232 

99.  Fracture  of  the  tibia  alone 237 

100.  Dressing  for  treating  the  leg  after  fracture  of  the  tibia 238 

101.  Double  fracture  of  the  fibula 241 

102.  Potts' fracture  of  the  fibula 242 

103.  Fracture  of  the  fibula  and  dislocation  of  the  ankle 243 

104.  Dressing  for  Potts'  fracture  of  the  fibula 245 

105.  Dupuytren's  dressing  for  Potts'  fracture 246 


DISLOCATIONS. 


106.  Dislocation  of  the  lower  jaw 209 

107.  Appearance  of  the  face  produced  by  dislocation  of  the  lower  jaw.  292 

108.  Dislocation  of  the  head  of  the  humerus  inwards  (subcoracoid)...  317 

109.  New  socket  formed  under  the  coracoid  process 321 

110.  Subglenoid  dislocation  of  the  humerus 326 

111.  Subspinous  dislocation  of  the  humerus 329 

112.  Dislocation  of  the  elbow 336 

113.  Dislocation  of  the  elbow 338 

114.  Dislocation  of  the  head  of  the  radius  forwards 342 

115.  Dislocation  of  the  head  of  the  radius  backwards 343 

116.  Dislocation  of  the  carpus  backwards 350 

117.  Dislocation  of  the  carpus  forwards 351 

118.  Dislocation  of  the  first  phalanx  of  the  thumb  forwards 355 

119.  Dislocation  of  the  head  of  the  femur  upwards  and  backwards, 

upon  the  dorsum  of  the  ilium 361 

120.  Manner  of  reducing  dislocations  of  the  femur  by  the  manipulat- 

ing plan. 373 


x  ILLUSTRATIONS. 

neuu.  PAGE 

121.  Dislocation  of  the  head  of  the  femur  downwards,  into  the  thy- 

roid foramen 377 

122.  Dislocation  of  the  femur  forwards,  upon  the  pubes 381 

123.  Dislocation  of  the  patella. 388 

124.  Dislocation  of  the  tibia , 391 

125.  Lateral  dislocation  of  the  knee 394 

126.  Dislocation  of  the  foot  outwards 400 

127.  Dislocation  of  the  foot  backwards ..  403 


J 


The  improvements  and  modifications  which  have  recently 
taken  place  in  the  management  of  fractures  and  dislocations, 
and  the  fact  that  the  ordinary  text-books  to  be  found  in  every 
physician's  library  contain  too  little  on  the  nature  and  treat- 
ment of  these  lesions,  and  the  special  treatises  too  much,  have 
induced  me  to  venture  upon  the  task  of  preparing  a  work 
specially  adapted  to  the  wants  of  the  great  mass  of  medical 
men. 

Accidents  involving  fractures  and  dislocations  commonly 
fall  into  the  hands  of  the  nearest  and  most  available  practi- 
tioners, who  may  need  practical  suggestions  in  regard  to  the 
most  approved  methods  of  treating  this  class  of  injuries, 
especially  as  such  accidents  frequently  involve  great  profes- 
sional responsibility. 

On  account  of  the  roller  bandage  being  too  often  applied 
improperly,  I  have  endeavored  to  enforce  a  due  consideration 
of  the  dangers  attendant  upon  its  careless  application;  and 
have  urged  the  importance  of  employing  as  light  dressings 
in  each  lesion  as  are  compatible  with  efficiency. 

Lotions  of  various  kinds  which  have  generally  been  used 
in  the  treatment  of  fractures  do  not  meet,  with  my  approval, 
for  the  reason  that  they  induce  vesications  and  render  the 
patient  uncomfortable  in  many  ways.  A  bandage  which  is 
occasionally  wetted  will  not  maintain  equable  pressure,  and 
may  become  the  source  of  perilous  constrictions. 

In  treating  fractures  of  the  lower  extremities,  neither  the 
double  inclined  plane  nor  the  long  straight  splint,  secures  sat- 
isfactory results,  therefore  I  have  recommended  the  "natural 

(xi) 


xii  PREFACE. 

method"  of  producing  extension  and  counter-extension. 
The  cleverly  constructed  specimens  of  mechanical  art  winch 
have  lately  been  invented  to  obviate  shortening*,  may  gratify 
the  taste  of  those  who  have  ample  means  to  invest  in  novel- 
ties ;  but  the  majority  of  medical  men  can  not  afford  to  pur- 
chase more  apparatus  than  may  be  absolutely  needed,  conse- 
quently I  have  depicted  and  commended  the  simplest  methods 
of  treating  fractured  limbs.  I  have  not  advised  the  use  of 
any  appliance  that  could  not  be  extemporized  from  materials 
to  be  found  in  every  farm  house.  "  Sets  "  of  splints  and  ap- 
pliances serve  to  make  a  show  in  a  physician's  office,  but  only 
a  few  pieces  in  each  are  of  any  practical  utility,  even  if  fur- 
nished in  assorted  sizes.  A  moulded  or  carved  splint,  though 
made  especially  to  fit  a  case  under  treatment,  will  soon  !,<•(•(. UK- 
inapplicable  from  increase  or  subsidence  of  swelling.  A 
splint  carved  into  grooves  and  ridges  with  the  design  of  con- 
forming to  the  natural  outline  of  the  arm,  wrist,  and  hand,  is 
calculated  to  deceive  the  unwary  into  the  neglect  of  more 
simple  means,  which,  if  rightly  applied,  will  answer  1 
purposes.  It  is  therefore  advised  that  the  surgeon  construct 
from  thin  boards  of  soft  wood,  such  splints  of  requisite  width 
and  length  as  each  case  may  demand. 

I  have  designed  most  of  the  illustrations,  and  in  no  instance 
is  a  topic  introduced  for  the  purpose  of  exhibiting  an  old  pic- 
ture; and  no  subject  is  distorted  to  meet  the  requirements  of 
obsolete  diagrams. 

In  PART  SECOND,  well  directed  efforts  to  reduce  di>locations 
by  what  has  been  called  the  "manipulating  plan,"  are  en- 
couraged as  a  substitute  for  the  more  dangerous  method  of 
overcoming  displacements  by  the  aid  of  pulleys  and  other 
mechanical  means  for  multiplying  force.  Since  the  introduction 
of  anaesthesia  into  surgical  practice,  there  is  less  need  of  vio- 
lent measures  to  replace  luxated  bones.  It  is  now  known  that 
obstacles  to  the  easy  return  of  a  displaced  bone,  consist  essen- 
tially in  tense  tissues  which  can  generally  be  rendered  lax  by 


PREFACE.  xiii 

changing  the  position  of  the  dislocated  limb.  However,  it  is 
not  to  be  understood,  if  a  displaced  bone  can  not  be  reduced 
by  manual  dexterity  alone,  that  no  other  means  are  to  be 
tried.  But  the  manipulating  plan  in  intelligent  and  persever- 
ing hands,  has  been  so  generally  successful,  that  it  would  be 
rash  to  try  harsher  means  until  repeated  and  varied  trials  of 
the  "physiological  method"  have  failed. 

In  preparing  this  work  on  Fractures  and  Dislocations,  I 
have  taken  the  liberty  of  drawing  from  every  available  source 
of  information,  and  have  not  always  given  credit  for  material 
employed.  This  omission  did  not  arise  from  a  reckless  dispo- 
sition to  appropriate  the  ideas  of  others ;  but  in  an  early 
attempt  to  give  each  author  his  due,  I  found  that  A  had  drawn 
from  B,  and  B  from  C,  and  so  on,  and  therefore  I  abandoned 
an  undertaking  which  at  best  must  have  been  imperfect, 
laborious,  and  unsatisfactory. 

In  presenting  this  book  to  the  profession,  it  is  with  no  in- 
flated estimation  of  its  merits;  indeed  I  know  it  has  glaring 
defects, — some  of  which  may  be  placed  to  a  lack  of  time  for 
carefully  correcting  and  amending  what  has  been  prepared 
amid  countless  interruptions,  and  during  the  busiest  of  pro- 
fessional life.  Whether  it  will  accomplish  what  I  have  de< 
signed,  time  and  readers  must  decide.  It  is  offered  as  a  guide 
to  the  multitude  of  practitioners  scattered  through  the  coun- 
try, who  have  comparatively  limited  facilities  for  becoming 
acquainted  with  the  best  methods  of  treating  a  class  of  inju- 
ries which  often  baffle  the  most  experienced  surgical  talent. 


I. 


FRACTURES. 


CHAPTER    I. 
FRACTURES. 

GENERAL  OBSERVATIONS  UPON  THEIR  NATURE  AND  TREATMENT. 


THE  bones  preserve  the  outline  of  the  human  figure,  giving 
support  and  protection  to  the  soft  tissues ;  and  serve  the  pur- 
pose of  levers  upon  which  muscular  force  is  displayed.  Hav- 
ing a  large  proportion  of  earthy  matter  in  their  composition, 
they  are  necessarily  brittle,  breaking  under  the  influence  of 
unusual  forces,  directly  or  indirectly  applied. 

When  a  muscle,  tendon,  ligament,  or  other  soft  structure,  is 
mechanically  separated,  the  injured  part  is  said  to  be  torn,  rup- 
tured, or  lacerated  ;  but  the  forcible  separation  of  a  bone  into 
two  or  more  pieces,  is  always  called  ^fracture. 

Bones  are  organized  structures ;  when  they  are  broken,  the 
reparative  processes  can  mend  or  consolidate  the  fragments, 
rendering  a  fractured  arm  or  leg  as  strong  as  ever  in  the  course 
of  a  few  weeks.  That  the  uniting  forces  may  be  as  efficient 
as  possible,  the  fragments  of  bone  must  be  kept  in  apposition. 

The  healing  action  firmly  joins  the  pieces  after  they  have 
been  adjusted  and  retained  in  then*  places ;  and  it  is  the  office 
of  the  surgeon  to  place  the  broken  parts  in  their  right  posi- 
tion, and  to  hold  them  there  by  the  use  of  such  appliances  as 
the  nature  of  each  case  demands. 

Fractures  vary  in  extent  and  direction,  and  the  forces  act- 
ing upon  the  fragments  produce  a  variety  of  deformities,  there- 
fore it  becomes  important  to  draw  distinctions  between  them, 
and  to  lay  down  some  definite  rules  for  their  recognition  anc1 
successful  management.  The  principles  of  diagnosis  and  treat- 
ment have  become  so  well  established  that  the  surgeon  who 
tails  to  perform  his  duties  according  to  the  most  approved 
rules,  is  held  responsible  for  such  detects  and  deficiencies 
us  are  justlv  chargeable  to  bis  negligence  or  ignorance; 
•2  "  (17) 


18  FRACTURES. 

and  the  practitioner  of  medicine  and  surgery  cannot  undertake 
to  treat  a  fracture  without  placing  his  professional  reputation 
in  jeopardy,  and  assuming  the  risks  of  vexatious  and  expen- 
sive litigation. 

Fractures  are  primarily  divi  k"l  into  two  classes,  the  fi)rj>le 
and  the  conipoantL  In  a  simple  fracture  the  lesion  is  uncom- 
plicated with  injuries  of  the  soft  tissues.  A  compound 
fracture  has  for  its  essential  character  a  wound  of  the  skin. 
with  which  the  fracture  communicates.  There  are  two  ways 
in  which  the  wound  may  be  produced  at  the  time  of  the  acci- 
dent : —  from  without,  by  the  direct  force  which  fractures 
the  bone ;  or  from  within,  by  the  end  of  one  or  both  fragments 
being  thrust  through  the  soft  parts,  either  by  the  continu- 
ance of  the  original  force,  or  by  the  weight  of  the  body.  The 
latter  mode  is  the  more  frequent;  consequently  compound 
fractures  are  more  common  in  the  leg  than  in  any  other  part 
of  the  body.  If  caused  by  direct  force  the  contusion  will  bo 
considerable,  and  likely  to  be  followed  by  inflammation,  suppu- 
ration and  sloughing ;  if  simply  incised  or  lacerated  by  the  pro 
trusion  of  a  sharp  fragment  of  bone,  the  wound  may  unite  by 
first  intention,  converting  the  compound  into  a  simple  fracture. 
It  may  be  remarked  in  this  connection,  that  a  fracture,  simple 
at  first,  may  be  rendered  compound  by  ulceration  of  the  skin 
over  a  broken  subcutaneous  bone,  as  in  oblique  fracture  of  the 
tibia;  and  by  the  formation  and  bursting  of  an  abscess  at  the 
seat  of  injury. 

The  partial  fracture  exists  only  when  a  portion  of  the  bone 
breaks,  the  fracture  stopping  before  it  extends  completely 
through  its  substance,  so  as  to  leave  the  fractured  portions  still 
continuous  in  some  part  with  the  rest  of  the  bone.  This  lias 
been  graphically  called  the  "green-stick"  fracture.  In  the  com- 
plete fracture  all  continuity  is  destroyed,  and  the  portions  of 
bone  are  separated  from  one  another  :  in  the  former  kind  the 
limb  seems  to  be  bent,  while  in  the  latter  there  is  generally, 
though  not  always,  more  or  less  displacement  of  the  fractured 
ends,  giving  the  limb  an  angular,  twisted  and  strongly  marked 
deformity.  The  partial  fracture  is  exceedingly  rare,  the  com- 
plete very  common. 

A  fracture  is  said  to  be  comminuted,  when  the  bone  is  broken 
into  many  small  pieces,  some  of  which  are  often  completely 
separated  from  the  periosteum,  losing  all  source  of  nourish- 


GENERAL  OBSERVATIONS.  19 

nient,  and  requiring  to  be  removed  either  naturally  or  artifici- 
ally, before  the  other  fragments  ean  unite. 

A  complicated  fracture  denotes  the  additional  lesion  of  an  im- 
portant blood-vessel  or  nerve,  or  the  extension  of  the  fracture 
into  a  neighboring  joint.  Fractures  are  not  unfrequentiy 
attended  with  such  serious  complications  that  death  is  the  re- 
sult. If  a  fracture  extend  into  a  joint,  the  high  degree  of  in- 
flammation, and  the  interference  of  the  reparative  material, 
often  bring  about  partial  or  complete  anchylosis.  A  compound 
fracture  is  necessarily  complicated  :  the  tlesh  is  lacerated  or 
contused,  rendering  the  injury  very  serious  in  its  nature.  A 
frac-ture  complicated  with  much  bruising  and  laceration  of  the 
soft  parts,  requires  a  long  period  to  undergo  reparation.  The 
primary  shock,  and  the  subsequent  suppuration,  tell  upon  the 
patient's  health  ;  ami  the  pus  and  debris  about  the  ends  of  the 
hones,  prevent  a  speedy  union  of  the  fragments. 

The  fragments  of  a  simple,  uncomplicated  fracture, ordina- 
rily become  consolidated  in  rive  or  six  weeks,  yet  as  many 
months  may  be  consumed  in  the  repair  of  a  compound  injury 
\vitli  perverse  complications. 

The  direction  a  fracture  takes  may  be  ol>I!f/ne  or  //•<///.->•'• 
though  the  line  of  separation,  in  a  strict  sense  of  those  terms, 
is  rarely  the  one  or  the  other.  The  manner  in  which  the  in- 
jury is  received,  has  some  influence  over  the  direction  of  the 
fracture.  Direct  violence  produces  fractures  more  transverse' 
than  oblique ;  and  an  indirect  force,  as  when  a  person  in  a  fall, 
strikes  upon  the  feet  and  receives  a  fracture  of  the  leg,  favors 
obliquity  in  the  line  of  separation,  especially  if  the  fracture 
occurs  to  the  shaft  of  the  bone.  Fractures  near  the  extremities 
of  long  bones,  and  in  the  flat,  and  irregular  shaped,  as  the  scap- 
ulfe  and  vertebrae,  are  apt  to  be  more  transverse  than  oblique. 

When  the  lines  of  separation  radiate  from  a  central  point  of 
the  bone,  at  which  the  violence  was  received,  they  are  regarded 
as  stellate  ;  and  when  the  broken  ends  of  bone  are  full  of  spicula 
or  serrations,  which  may  interlock  like  opposing  teeth,  the  frac- 
ture is  dentate. 

The  course  of  the  fracture  has  a  bearing  on  the  reduction  of 
the  fragments,  and  their  retention  in  apposition.  Transverse 
fractures,  especially  if  they  be  dentate,  when  once  reduced,  are 
not  easily  displaced ;  and  these  conditions  often  present  obstacles 
to  ready  reduction.  If  the  line  of  separation  be  oblique  the 


20  FRACTURES. 

reduction  is  not  difficult,  but  there  is  a  disposition  on  the  part 
of  the  fragments  to  slide  past  each  other. 

As  may  naturally  be  supposed,  all  bones  are  not  equally 
liable  to  fracture.  Some  are  more  exposed  to  injury  than 
others,  and  some  are  increased  or  diminished  in  strength  by 
their  shape.  It  is  plainly  observable  that  the  long  bones  are 
the  most  frequently  fractured,  while  the  short  ones  are  com- 
paratively seldom  broken,  and  always  by  direct  violence. 

There  are  certain  morbid  conditions  of  the  bones  which  ren- 
der them  unusually  fragile.  Rickets,  caries,  necrosis,  cancer, 
scrofula  and  syphilis,  may  so  affect  the  bones  that  they  are  lia- 
ble to  break  from  very  slight  causes.  A  dozen  fractures,  occur- 
ring at  different  times,  and  from  trivial  forces,  have  been 
treated  in  a  boy  under  twelve  years  of  age.  Three  of  them 
were  of  the  right  humerus,  and  occurred  in  the  act  of  throwing 
a  stone.  Esquirol  possessed  the  skeleton  of  a  woman,  in  which 
the  traces  of  more  than  two  hundred  fractures,  occurring  at 
different  periods,  could  be  counted.  The  peculiar  liability  to 
fracture  in  the  bones  of  certain  individuals  does  not  necessarily 
retard  the  uniting  process.  In  some  instances  the  recovery  is 
unusually  rapid.  Stanley  records  one  case,  however,  in  which 
it  was  difficult  to  obtain  a  union. 

There  is  a  tendency  to  fracture  in  old  people,  from  the 
fact  that  their  bones  become  chemically  altered  ;  the  earthy 
matter  predominates  over  the  animal,  a  condition  which  favors 
brittleness.  In  young  people,  the  disproportion  in  the  compo- 
nent parts  is  reversed;  the  animal  matter  predominates,  so  that 
the  bones  bend  under  the  weight  of  the  body,  or  under  the 
action  of  the  muscles.  Children  with  bow-legs  usually  have  a 
deficiency  of  lime  in  the  skeleton. 

A  disproportion  between  the  strength  of  the  bones  and  the 
power  of  the  muscles  also  predisposes  to  fracture.  Great  mus- 
cular development,  coupled  with  a  rapidly  acting  nervous  sys- 
tem, may  prove  too  powerful  for  slender  bones.  The  hunio- 
rus  and  the  femur  have  both  been  broken  simply  by  muscular 
exertion.  The  olecranon,  patella,  and  the  os  calcis  are  levers 
which,  while  enduring  violent  and  sudden  forces  from  the  mus- 
cles acting  upon  them,  are  occasionally  broken.  Few  bones 
are  placed  at  such  disadvantage  for  resisting  muscular  action. 

Tables  drawn  up  to  exhibit  the  comparative  frequency  of 
fractures  in  the  different  bones,  vary  somewhat.  According  to 


GENERAL  OBSERVATIONS.  21 

some  authors  the  ribs  are  the  most  frequently  fractured ;  the 
clavicle  standing  next  in  the  order  of  frequency ;  the  radius 
taking  the  third  place ;  the  humerus  the  fourth ;  the  femur  the 
fifth  ;  the  fibula  the  sixth  ;  and  the  tibia  the  seventh.  Both 
bones  of  the  leg  are  broken  at  the  same  time  more  frequently 
than  either  singly.  According  to  my  own  observation  and 
experience  the  radius  is  the  most  frequently  broken,  the  clav- 
icle next,  and  the  ribs  take  the  third  place. 

\Vhen  a  bone  breaks  at  the  point  where  force  is  applied  the 
fracture  arises  from  direct  violence  ;  a  fracture  of  the  radius  or 
hurnerus  arising  from  a  fall  on  the  hand,  is  said  to  be  by  coun- 
ter-stroke (contre-cottp),  or  indirect  violence.  A  person  falling 
from  a  height  and  striking  upon  the  feet,  does  not  sustain  a 
fracture  of  the  calcaneum  or  metatarsal  bones,  but  the  force 
is  transmitted  through  the  foot  to  the  tibia,  or  even  through  it 
to  the  femur,  and  acts  indirectly  to  a  degree  that  severs  one  of 
those  long  bones  at  a  weak  point.  The  radius  commonly 
gives  way,  from  indirect  violence,  near  its  lower  extremity  ; 
the  humerus  at  the  external  condyle ;  the  femur  just  below  the 
tro chanters,  the  tibia  through  its  lower  third.  The  fibula  is 
often  broken  by  a  twisting  force  in  the  fall  of  the  body  to  the 
ground  after  the  tibia  has  yielded  to  the  counter-stroke.  It 
is  reasonably  supposed  that  muscular  tension  has  something 
to  do  with  fractures  commonly  considered  as  taking  place 
from  indirect  violence,  for  a  dead  body  may  be  let  fall  the 
same  distance  and  it  will  receive  no  broken  bones  from  the 
counter-stroke.  The  loose  and  passive  condition  of  the  bodies 
of  drunkards  seems  to  shield  them  from  fractures  while  sus- 
taining fearful  falls. 

A  person  in  falling  from  a  height,  often  seizes  at  some  object 
to  arrest  his  descent,  or  strikes  some  object  on  the  way  down, 
either  of  which  imparts  a  whirling  motion  to  the  trunk,  so 
that  in  accounting  for  the  injury  upon  the  theory  of  counter- 
stroke,  the  compound  motion  should  be  estimated. 

The  great  degree  of  bruising  of  the  soft  parts,  with  ecchy- 
mosis,  is  sufficient  in  some  situations  to  prevent  the  fracture 
from  being  discovered.  This  is  often  the  case  in  crushing 
injuries  of  the  hand  or  foot.  Direct  violence  of  a  crushing 
nature,  applied  near  the  joints,  may  break  the  articular  surfaces, 
causing  effusions  and  swelling  which  tend  to  obscure  the  real 
nature  of  the  injury. 


CHAPTER    II. 
SIGNS    OF    FRACTURE. 


The  symptoms  of  fracture  are  quite  distinct  and  reliable. 
The  patient  hears  a  snap  at  the  time  of  receiving  the  injury. 
and  feels  such  a  piercing  pain,  that  the  nature  of  the  lesion  is 
impressed  upon  the  mind  of  the  sufferer.  Loss  of  power  in 
the  part  implicated,  and  unnatural  mobility  at  the  point  of 
injury,  causing  the  limb  to  assume  unusual  twists  and  angular 
deformities,  arc  peculiar  to  fracture.  Crepitus,  when  it  ran 
be  elicited,  is  the  most  decisive  of  all  the  signs  of  fracture. 

The  snap,  whether  heard' by  the  patient,  or  by  persons  who 
chance  to  be  near,  is  a  symptom  of  some  value,  though  the 
sound  may  be  produced  by  other  causes,  such  as  the  rupture 
of  tendons,  ligaments,  or  the  breaking  of  a  stick  or  other  for- 
eign substance  at  the  time  the  injury  is  received.  It  is  almost 
impossible  for  a  fracture  to  occur  without  a  loud  and  distinct 
snap  being  produced,  yet  the  sound  is  heard  in  only  a  small 
proportion  of  cases. 

Pain  is  not  a  reliable  sign  of  fracture,  for  it  is  sometimo 
slight, being  scarcely  complained  of  unless  motion  be  imparted 
to  the  fragments.  However,  in  most  instances,  the  pain  is  so 
acute  and  agonizing  that  it  calls  forth  cries  of  distress,  elicit- 
ing the  deepest  sympathy.  In  fractures  that  have  existed 
several  hours,  the  swelling  having  cheeked  the  preternatural 
mobility  and  masked  the  deformity,  the  pain  which  maybe 
produced  by  motion,  becomes  a  valuable  diagnostic  sign.  If 
the  finger  be  passed  slowly  and  carefully  over  the  whole  length 
of  the  suspected  bone,  the  absence  of  all  pain  on  pressure 
proves  its  integrity,  unless  the  parts  have  been  subjected 
directly  to  external  violence.  On  the  contrary,  the  exist eii' •«• 
of  pain,  more  or  less  severe,  at  a  circumscribed  spot,  would 
afford  strong  presumptive  evidence  of  fracture. 

(22) 


SIGNS  OF  FRACTURE.  23 

Loss  of  power  in  a  limb  is  not  necessarily  a  diagnostic  sign 
of  considerable  importance.  A  patient  with  a  fractured  radius 
can  often  use  the  hand  to  the  astonishment  of  by-standers 
who  afterwards  learn  the  true  nature  of  the  injury ;  a  broken 
fibula  does  not  always  restrain  a  patient  from  walking ;  and  a 
man  with  a  fractured. cervix  femoris  has  been  known  to  use 
the  limb  with  a  freedom  truly  puzzling.  The  impaction  of 
tho  fragments  and  the  interlocking  of  the  serrations  may 
account  in  part  for  these  seeming  anomalies  or  inconsistencies. 

It  is  certainly  true  that  in  most  instances  fractures  inflict  a 
notable  hindrance,  or  an  entire  incapacity,  of  motion  in  the 
limb.  The  patient  generally  expresses  his  inability  to  use  the 
fractured  limb,  and  refuses  to  make  even  moderate  effort, 
being  intuitively  conscious  of  the  loss  of  power. 

The  swelling  attendant  upon  a  fractu  red-injury  may  take 
place  immediately,  or  not  be  marked  for  several  days.  At 
the  instant  of  fracture  there  is  often,  but  not  always,  an 
effusion  of  blood  around  the  fragments,  and  an  extravasation 
into  the  surrounding  tissues,  constituting  strictly  an  internal 
ecchymosis,  which  may  not  betray  itself  unless  the  tissues  are 
laid  open.  This  effused  or  extravasated  blood,  especially  in 
elderly  patients,  finds  its  way  gradually  to  the  integuments 
at  quite  a  distance  from  the  seat  of  injury,  discoloring  the 
limb  to  an  extent  which  excites  alarm. 

In  fractures  communicating  with  a  joint,  the  blood  mixes 
with  the  synovial  fluid,  and  contributes  not  a  little  to  the 
general  tumefaction.  The  swelling  following  a  fractured 
patella  may  be  so  great  that,  if  the  injury  be  not  seen  for  two 
days  after  the  accident,  it  is  very  difficult  to  determine  the 
nature  of  the  lesion.  The  same  obscurity  attends  fractures 
into,  or  near  all  the  joints,  if  the  patient  be  not  examined 
soon  after  the  accident  has  occurred. 

Preternatural  mobility  is  a  characteristic  sign  of  fracture. 
To  develop  this  decisive  diagnostic  symptom  one  fragment 
must  be  held  fixed  while  the  other  is  moved  in  different 
directions;  the  limb  is  then  observed  to  bend,  the  angle  being 
at  the  seat  of  fracture,  indicating,  at  once,  a  solution  of  con- 
tinuitv  in  the  bone.  In  the  clavicle,  the  mere  weight  of  the 

•  O 

shoulder  will  produce  the  angle,  and  if  the  arm  be  grasped 
and  moved  up  and  down  the  mobility  can  be  readily  discov- 
ered. 


24  FRACTURES. 

Motion  can  be  easily  produced  in  the  shafts  of  the  long 
bones,  which  have  been  fractured,  but  it  is  not  so  readily 
demonstrated  when  the  solution  of  continuity  is  near  joints. 
The  portion  of  bone  connected  with  the  articulation,  is  so 
small  or  short,  that  it  can  not  be  easily  fixed  so  the  long  frag- 
ment can  be  moved  upon  it.  And  then,  the  natural  move- 
ments of  the  joint  in  such  immediate  proximity  to  the  frac- 
ture, tend  to  obscure  the  mobility  peculiar  to  the  lesion.  In 
fracture  of  the  radius  through  its  carpal  extremity,  very  little 
mobility  can  be  developed  by  manipulation  of  the  parts. 

Displacement  of  the  fragments  is  betrayed  by  the  change  in 
the  form  of  the  limb;  often  an  experienced  surgeon  can  at  a 
glance  divine  the  nature  of  the  injury  by  the  deformity.  It 
would  be  unsafe  to  trust  too  much  to  tirst  appearances;  the 
deformity  might  be  due  to  luxation  or  to  a  severe  contusion. 

If  a  fractured  limb  present  a  bend  or  angle  at  a  point  wi 
none  should  exist,  the  sign  is  valuable.    One  fragment  resting 

*  C7  O 

iii  front  or  to  one  side  of  the  other,  constituting  a  salient 
projection  which  can  not  only  be  seen,  but  felt  as  the  lingers 
are  pressed  along  the  bone,  is  quite  decisive  as  to  the  nature 
of  the  injury;  deformity  by  rotation,  as  when  the  hand 
or  foot  is  twisted  around  into  an  awkward  position  after  frac- 
ture of  the  arm.  or  leg,  indicates  what  kind  of  an  injury  has 
been  sustained.  Shortening  of  a  limb,  which  can  generally 
be  determined  by  measurements  between  prominent  points  in 
the  skeleton,  is  a  sign  of  great  value  in  establishing  a  diagno- 
sis. If  there  be  no  displacement,  the  spicula  of  the  fragments 
hold  each  other  interlocked,  so  that  no  shortening  is  percep- 
tible. Fractures  of  the  olecranon,  patella,  and  os  calcis,  are 
apt  to  be  attended  with  a  considerable  degree  of  .*t>/><ir<itit.>n 
between  the  fragments.  Muscular  action  is  the  cause  of  thU 
displacement,  and  it  always  produces  more  or  less  deformity 
after  fractures  ;  it  twists  fragments  of  the  fibula  away  from 
each  other  ;  and  in  fractures  of  the  forearm,  it  drags  the  frag- 
ments of  the  radius  and  ulna  into  contact-  with  one  another, 
and  if  the  pieces  of  bone  be  not  kept  in  their  proper  relation-. 
all  the  fragments  may  lie  so  united  as  to  prevent  rotation. 

Crepitus  is  a  grating  sound,  produced  by  rubbing  one  frag- 
ment of  bone  against  another.  It  is  the  most  positive  of  all 
the  signs  of  fracture,  though,  unfortunately  as  a  diagnostic 


SIGNS  OF  FKACTUUE.  25 

symptom,  it  cannot  always  be  elicited  on  account  of  the  inter- 
locking of  the  ends  of  the  fragments. 

If  there  be  much  separation  between  the  fragments,  as 
there  usually  is  in  fractures  of  the  patella,  crepitus  can  not, 
for  obvious  ivasons,  be  elicited  ;  and  extensive  overlapping  is 
also  opposed  to  the  production  of  crepitation.  A  coagulum 
of  blood,  piece  of  muscle,or  other  soft  tissue  interposed  between 
the  ends  of  broken  bones  may  interfere  mechanically  to  prevent 
crepitus  ;  and  many  other  conditions  are  opposed  to  the  suc- 
cess of  efforts  designed  to  elicit  crepitation. 

It  often  happens  in  fractures  through  the  neck  of  the  thigh 
bone,  that  free  motion  can  be  produced,  yet  no  crepitus  is 
elicited,  one  portion  of  bone  being  drawrn  up  beyond  the  other. 
In  these  cases  if  the  limb  be  extended,  so  as  to  bring  the 
ends  of  the  fragments  in  apposition,  and  the  leg  be  rotated, 
a  distinct  crepitus  can  be  obtained. 

In  the  majority  of  fractures  the  crepitus  can  be  distinctly 
feit  and  heard  ;  therefore  as  a  sign  of  fracture  it  is  extremely 
valuable.  To  the  patient  and  bystanders,  who  hear  the  crep- 
itation, the  sound  is  particularly  convincing.  The  surgeon 
enjoys  a  double  satisfaction  in  the  sound,  for  it  not  only  gives 
decisive  evidence  of  the  nature  of  the  injury,  but  proves  that 
the  fragments  are  in  juxta-position,  no  muscle  or  other  struc- 
ture intervening. 

The  snapping  of  tendons,  and  the  crackling  of  emphysema- 
tous  tissues,  resemble  slight  or  indistinct  osseous  crepitus,  yet 
the  surgeon,  manipulating  the  injury,  feels  rather  than  hears 
the  crepitation,  and  judges  or  discriminates  by  that  sense. 
Crepitus  can  be  made  most  distinct  soon  after  the  reception 
of  a  fracture  ;  the  changes  which  take  place  in  the  course  of 
the  inflammatory  stages  of  the  injury,  and  the  healing  pro- 
cess, thwart  all  efforts  to  elicit  crepitation. 

Fractures  are  often  dangerous  injuries.  The  violence  pro- 
ducing them  may  be  of  such  a  nature  as  to  lacerate  the  soft 
tissues,  and  to  inflict  the  most  serious  wounds.  The  sharp 
ends  of  the  fragments  sometimes  sever  or  puncture  large 
blood-vessels,  and  destroy  the  integrity  of  important  nerves, 
subjecting  the  parts  involved  to  the  dangers  of  gangrene  or 
extensive  sloughs.  Not  unfrequently  an  injury  involving  a 
fracture,  is  of  such  a  serious  nature  that  amputation  becomes 
imperative.  Fractures  extending  into  the  joints  always  excite 


26  FKACTTKKS. 

tho  gravest  apprehensions;  they  may  turn  out  well,  yet  there 

is  110  certainty  of  a  perfect  result.  Partial  or  complete  anchy- 
losis is  a  common  sequence  of  fractures  involving  an  articula- 
tion. 

Other  injuries  often  simulate  fractures,  therefore  the  surgeon 
must  discriminate  between  the  symptoms  of  dislocations, 
sprains,  fractures,  and  other  lesions.  A  differential  diagnosis 
cannot  always  be  made  out  until  the  patient  is  placed  under 
the  influence  of  chloroform.  The  peculiarities  of  dislocation 
must  be  well  understood,  or  the  differences  between  the  signs 
of  the  two  injuries  will  not  be  apparent.  It  must  be  known 
that  a  fractured  limb  is  characterised  by  unusual  mobility, 
and  that  a  dislocated  one  is  unnaturally  rigid  ;  that  a  fractured 
bone  is  easily  reduced  but  it  will  not  stay  in  place,  and  a  dis- 
located one  is  difficult  to  reduce,  but  once  returned  to  its  nor- 
mal position,  it  will  generally  stay  there.  An  examination 
and  comparison  of  the  most  prominent  processes,  in  fractures 
near  the  joints,  may  preclude  error  of  diagnosis.  In  a  severe 
bruise  or  strain  the  real  condition  of  the  injury  can  be  deter- 
mined by  a  negative  method  of  examination  and  reasoning. 
If  it  be  satisfactorily  demonstrated,  in  a  doubtful  case,  that 
neither  a  fracture  nor  a  dislocation  exists,  the  logical  conclu- 
sion is  that  the  lesion  is  a  sprain,  bruise,  or  contusion. 

Children  sometimes  receive  serious  injuries  that  are  excerd- 
ingly  difficult  to  recognize.  They  are  unable  to  tell  how  the 
hurts  were  received,  or  to  give  an  intelligent  explanation  of 
the  pain  or  other  conditions  of  the  parts  implicated  in  the 
injury.  Their  fright,  sobs,  and  agitation,  thwart  the  hot 
directed  efforts  to  understand  the  nature  of  the  accident  : 
sometimes  it  is  best  to  postpone  the  examination  until  the 
child  has  recovered  from  its  nervous  condition. 

Incomplete  fracture,  when  it  exists,  and  that  is  seldom,  must 
necessarily  be  confined  to  the  young.  The  bones  of  old  sub- 
jects, from  the  amount  of  earthy  matter  in  their  composition. 
break  like  a  dry  stick.  The  bones  of  the  arm  are  most  liable 
to  the  partial  or  "green-stick"  fracture  (Figure  1).  The 
humerus,  during  childhood,  has  been  found  bent.  It  then 
ofters  considerable  resistance  to  straightening  or  reduction. 
The  child  is  averse  to  motion  in  the  limb,  and  guards  ir 
against  subsequent  injury.  An  attempt  at  quirk  and  forcible 
reduction  may  complete  the  tract u re. 


SIGNS  OF  FRACTURE. 


Fissure  of  a  bone  is  commonly  an  obscure  injury  to  diag- 
FIO.  i.  nose.  In  most  instances  of  suspected  fissure  the 
evidence  must  be  founded  on  what  is  little  better 
than  conjecture.  The  bone  could  not  well  be  fis- 
sured without  tearing  the  periosteum  and  the 
medullary  membrane  ;  and  the  suffering  would  be 
long  continued.  The  danger  of  these  cases  is 
illustrated  by  an  example  from  Duverney.  A  man 
received  a  kick  from  a  horse  on  the  center  of  the 
left  tibia.  This  was  followed  by  severe  pain  and 
sloughing  of  the  skin,  which,  however,  readily 
healed,  and  the  patient  went  about  as  cured. 
Three  months  later  he  was  again  confined  to  his 
bed  by  the  accession  of  sudden,  acute  pain.  After 
much  ineffectual  treatment  by  emollients,  the  bone 
was  exposed,  and  a  long  deep  fissure  was  found,  the 
edges  of  which  were  raised  twice,  giving  exit,  on 
the  second  occasion,  to  pus.  Subsequently  the 
a u!-e?  bone  was  trephined,  and  an  abscess  laid  bare  in 

the  medullary  cavity. 

Railway  accidents  produce  fractures  which,  from  their  com- 
plications, and  serious  nature,  deserve  to  be  considered  by 
themselves.  The  severer  forms  of  injury,  from  the  paralyz- 
ing character  of  the  shock,  and  the  number  of  parts  impli- 
cated in  the  lesion,  are  apt  to  terminate  fatally.  An  arm  or 
leg,  suffering  from,  fracture  by  a  rail  road  accident,  is  generally 
so  badly  bruised  and  mashed,  that  it  may  require  amputation. 
In  1868,Dr.  C.  E.  Witham,  of  Walton,  Iowa,  was  called  to 
take  professional  charge  of  a  man  who  received  a  fracture  of 
both  bones  of  the  forearm  while  shackling  cars.  In  the 
course  of  twenty  hours  from  the  time  of  the  accident,  reac- 
tion having  taken  place  in  the  entire  bod}*  except  the  injured 
limb,  which  remained  cold  and  pulseless,  the  docter  in  con- 
sultation with  two  other  physicians,  decided  to  amputate  the 
arm.  The  injury  was  of  such  a  crushing  character  that  it 
was  presumed  the  limb  would  slough,  and  greatly  endanger 
the  patient's  life.  The  three  medical  men  in  council,  had  no 
misgivings  in  regard  to  the  requirements  of  the  case.  There 
seemed  to  them  an  imperative  necessity  for  amputation,  and 
they  accordingly  removed  the  limb.  The  patient  made  a  good 
recovery,  and  for  the  time  appeared  satisfied  with  the  opera- 


28  FRACTURES. 

tion  ;  but  some  rival  physicians  got  posession  of  the  amputa- 
ted limb,  and  injected  the  arteries  ;  the  vessels  proved  to  be 
untorn,  at  least  they  sustained  an  injection.  The  young 
man  who  had  lost  the  arm  was  made  to  believe  that  his  limb 
had  been  needlessly  sacrificed,  and,  therefore,  sued  Dr.  Witham 
and  his  associates,  for  damage  to  the  extent  of  ten  thousand 
dollars. 

A  breakman  on  a  freight  train  gets  a  leg  or  an  arm  broken 
by  the  moving  cars,  or  receives  a  crushing  injury  by  being 
thrown  from  his  position.  The  shock  may  be  so  great  that 
he  will  never  react;  or  he  may  die  from  a  multiplicity  of  in- 
juries, that  do  not  manifest  themselves  at  first.  A  question 
arises,  in  the  contemplation  of  these  terrible  injuries,  what  is 
bestto  be  done?  Ordinary  rules  applicable  in  surgical  injunc-. 
fail  to  meet  the  exigencies  of  the  cases.  A  conservative 
course,  which  in  ordinary  accidents  succeeds  so  well,  too  often 
fails  in  these  dangerous  injuries.  To  attempt  to  save  a  limb 
that  has  suffered  a  compound,  comminuted,  and  complicated 
fracture,  may  result  in  the  sacrifice  of  lite. 

Threshing  machines,  sorghum  mills,  and  other  modern 
agricultural  implements,  to  say  nothing  of  the  powerfully 
moving  machinery  of  our  great  manufactories,  are  constantly 
producing  fractures  and  other  injuries  which  tax  the  skill  and 
ingenuity  of  the  most  experienced  surgeons. 

If  the  principal  arteries  and  nerves  of  a  limb  be  lacerated 
or  severely  injured,  the  hope  of  recovery  without  amputation 
quite  frequently  proves  illusive.  However,  in  doubtful  cases 
it  is  well  to  wait  for  reaction  and  other  recuperative  sign.-. 
There  is  danger  in  resorting  immediately  to  operative  nie-as.- 
ui'fs.  While  a  patient  niignt  not  know  that  lie  had  lost  a 
limb  through  surgical  incompetence,  there  is  an  awful  respon- 
sibility in  the  procedure  which  a  lively  conscience  could  not 
easily  endure.  "Did  I  sacritice  a  limb  that  might  have  been 
saved?" 


CHAPTER    III. 
PROCESS    OF    UNION. 


The  dearth  of  opportunities  for  examining  broken  bones 
during  their  various  stages  of  repair,  has  prevented  that 
thorough  knowledge  of  the  changes  taking  place  from  day  to 
day  during  the  healing  process,  which  is  so  interesting  and  in- 
structive. Experiments  upon  animals  have  contributed 
something  to  a  better  understanding  of  the  subject,  yet  vary- 
ing conditions  have  stood  in  the  way  of  rigid  comparisons. 
In  man,  a  steady  unvarying  course  of  repair  is  not  to  be  ex- 
pected in  all  cases.  One  person  with  fracture  of  the  tibia 
may  walk  on  the  limb  in  five  or  six  weeks  from  the  accident : 
another  person,  with  a  similiar  fracture,  and  every  condition 
seemingly  as  favorable,  may  not  walk  for  three  months :  in 
fact,  no  bony  union  may  take  place,  the  patient  having  to 
hobble  about  for  the  rest  of  life  with  a  false-joint  at  the  seat 
of  fracture,  the  connection  between  the  fragments  being  lig- 
amentous  and  not  osseous. 

In  the  simplest  forms  of  fracture,  where  the  periosteum  is 
not  much  damaged,  and  the  soft  tissues  are  not  severely 
braised,  the  healing  process  sets  in  earlier  and  terminates 
sooner,  than  in  compound,  complicated,  and  comminuted 
fractures.  The  effusion  of  considerable  blood  is  tm  obstacle 
to  early  efforts  at  repair.  If  the  periosteum  be  stripped  from 
the  fragments,  and  torn  into  shreds,  the  course  of  recovery 
will  necessarily  be  prolonged. 

During  the  tirst  few  days  the  inflammatory  action  runs 
high,  and  the  swelling  and  local  disturbances  create  serious 
trouble.  The  swelling  may  commence  as  soon  as  the  accident 
occurs,  or  come  on  anytime  within  a  day  or  two.  The  violence 
of  the  inflammatory  action  may  be  reached  on  the  second  day, 
but  there  is  no  marked  subsidence  for  five  or  six  davs.  This 

(29) 


30  FRACTURES. 

may  be  called  the  inflammatory  stage  of  the  difficulty.  For 
the  succeeding  five  days  the  swelling  subsides,  and  a  great 
part  of  the  effused  blood — the  debris  of  the  injury — is 
removed;  during  the  next  five  days  there  is  an  effusion  of 
plastic  material,  of  jelly-like  consistence, which  is  to  be  elabo- 
rated into  a  firmer  bond  between  the  fragments.  Fifteen  days 
have  now  passed,  and  the  union  is  a  "  rope  of  sand."  If  the 
parts  be  cut  into  and  examined,  the  extravasated  blood  will 
be  gone,  an  abundance  of  unorganized  lymph  will  be  seen 
between  and  about  the  fragments  of  bone,  and  the  muscles 
and  other  soft  tissues  adjacent  to  the  injury  will  seem  to  be 
glued  together.  The  lymph  is  yellowish  white,  but  the  sur- 
rounding structures  under  the  influence  of  the  reparative 
'action,  have  a  pinkish  hue,  the  reddish  color  coming  from 
minute  blood-vessels  which  are  pushing  their  way  into  tin1 
newly  forming  material.  Although  the  blended  soft  tissue 
around  the  bone  assist  in  giving  firmness  to  the  parts,  the 
fragments  themselves  move  about  as  freely  as  when  the  frac- 
ture first  occurred. 

Half  of  the  time  ordinarily  consumed  in  the  treatment  is 
now  passed,  and  the  real  work  of  repair  is  but  just  begun. 
During  the  next  five  days  the  plastic  lymph  becomes  organ- 
ized into  cells  and  fibrous  bands.  By  the  twentieth  day  the 
fragments  are  bound  together  by  this  newly  formed  connec- 
tive tissue,  so  that  there  is  considerable  firmness  established 
between  the  ends  of  the  fragments  and  the  surrounding 
structures.  The  limb  at  this  time  will  bend,  but  has  not  the 
mobility  peculiar  to  a  recent  fracture. 

From  the  twentieth  to  the  twenty-fifth  day  the  osseous 
corpuscles  are  deposited  in  the  meshes  of  the  fibrous  connec- 
tion. The  new  bony  material  is  thrown  out  first  and  most 
rapidly  from  the  periosteum  and  'the  medullary  membrane, 
but  is  not  placed  with  much  regularity.  At  first  there  is  an 
excess  of  corpuscles  at  one  point,  and  a  deficiency  at  another ; 
but  by  the  twenty-fifth  day,  in  a  young  patient,  under  favor- 
able circumstances,  the  bony  connection  is  sufficiently  abun- 
dant and  consolidated  to  sustain  itself  without  artificial  assist- 
ance. The  osseous  union  is  not  yet  complete  ;  in  places  there 
is  too  much  of  the  fibrous,  and  not  enough  of  the  bony  mate- 
rial ;  and  there  is  not  that  complete  consolidation  which  proves 
to  be  unyielding.  In  fractures  of  the  leg,  the  osseous  union 


PROCESS  OF  UNION.  31 

is  often  so  imperfect  by  the  thirtieth  day,  that  the  uniting 
material  may  yield,  allowing  of  shortening  in  cases  inclined 
to  overlap.  I  recently  took  oft'  a  dressing  from  a  fractured 
femur  that  had  been  on  thirty  days.  There  seemed  to  be  per- 
fect consolidation  of  the  fragments,  and  careful  measurement 
showed  that  the  legs  were  of  equal  length.  The  patient,  a 
lad  of  ten  years,  began  to  move  about  on  crutches,  and  grad- 
ually to  press  the  foot  of  the  lame  side  to  the  ground.  In  two 
weeks  after  the  fracture-dressings  were  removed,  I  again 
made  a  measurement,  and  found  that  the  fractured  limb  was 
fully  a  half  inch  shorter  than  its  fellow.  As  the  measurements 
in  both  instances  were  made  with  scrupulous  exactitude,  the 
conclusion  to  be  drawn  was  that  the  dressings  were  removed 
before  the  ossification  was  sufficiently  complete  or  consolidated 
to  resist  the  normal  muscular  tension. 

It  is  of  the  utmost  importance  that  the  surgeon  understand, 
as  nearly  as  possible,  what  is  going  on  from  day  to  day  in  the 
process  of  repair  in  a  fractured  bone.  The  differences  of  ac- 
tivity at  the  various  ages  of  life,  and  the  modifying  influences 
arising  from  the  kind  of  fracture,  and  from  the  region  of  body 
injured,  to  say  nothing  of  general  health,  and  minor  considera- 
tions, render  certainties  out  of  the  question,  and  leave  a  wide 
scope  for  conjecture  and  speculation. 

The  most  experienced  surgeon  can  not,  from  manipulation 
or  the  appearances  of  the  limb,  determine  positively  when  a 
fracture-dressing  may  be  removed.  If  every  part  of  the  treat- 
ment has  been  satisfactory,  and  there  be  no  known  reason  why 
the  healing  processes  have  not  accomplished  what  they  usually 
do  in  a  given  time,  it  may  be  presumed  that  a  good  union  has 
been  effected  in  four,  five,  or  six  weeks,  as  the  particular  case 
might  seemingly  require.  If  there  be  mobility,  crepitus,  or 
other  signs  of  non-union  at  a  time  when  a  complete  result 
ought  to  be  expected,  it  would  be  certain  that  the  fracture- 
dressing  should  be  continued  for  a  week  or  two,  but  there  is 
no  way  to  determine  just  how  many  more  days  the  treatment 
ought  to  be  continued,  nor  could  it  be  positively  determined 
whether  a  union  would  ever  occur.  After  four,  five,  or  six 
weeks  have  elapsed  from,  the  reception  of  the  injury,  and  upon 
the  removal  of  the  dressing  the  limb  is  found  to  be  firm  at  the 
point  of  fracture,  the  presumption  is  that  union  has  taken 


82  FRACTURES. 

place,  and  the  surgeon  would  feel  justified  in  laying  aside  the 
usual  retentive  supports. 

When  the  fragments  do  not  accurately  correspond,  the 
uniting  medium  occupies  externally  the  angle  between  them, 
and  extends  partly  into  and  across  the  medullary  canal.  When 
they  completely  overlap,  and  even  when  there  is  an  interval 
between  them,  provided  it  is  not  too  great,  the  same  rule  pre- 
vails. The  reparative  material  simply  extends  between  them, 
bridging  over  the  interval,  and  filling  up  all  angles  and  irreg- 
ularities. It  does  not  cover  the  free  ends  of  the  fragments, 
nor  occupy  the  medullary  canal. 

According  to  Dupuytren,  the  method  of  union  in  broken 
bones  is  by  a  superabundance  of  reparative  material  at  the 
seat  of  fracture,  called  "  provisional  callus."  It  may  be  likened 
to  the  mass  of  solder  employed  to  join  the  ends  of  two  pieces 
of  leaden  pipe,  or  to  a  "  ferule  "  on  a  whip-stock.  The  re- 
parative material  used  to  blend  or  weld  the  ends  of  the  frag- 
ments, and  not  carried  away  by  absorption  at  a  period  more 
or  less  remote,  takes  the  name  of  permanent,  "  definitive/'  and 
uniting  callus. 

Mr.  Paget  holds  that  the  mode  of  union  through  the  agency 
of  a  provisional  callus,  is  peculiar  to  the  process  of  reparation 
in  animals  whose  broken  bones  are  in  constant  motion,  or  not 
fixed  by  dressings.  He  teaches  that  the  only  bones  which 
normally  and  constantly  unite  by  this  process,  in  man,  are  the 
ribs,  the  motions  of  which  can  not  be  fully  restrained.  Occa- 
sionally it  is  seen  in  the  clavicle  and  humerus ;  rarely  in  the 
tibia,  fibula,  and  other  bones.  In  children,  whose  motions  it 
is  not  easy  to  restrain,  the  "  ensheathing  "  callus  is  quite  fre- 
quent ;  according  to  Hamilton,  almost  constant. 

Dupuytren  entertained  the  idea  that  the  provisional  callus 
was  intended  as  a  temporary  support  during  the  mobile  stages 
of  repair.  It  is  now  known  that  a  "  provisional  "  callus  is  not 
necessary  in  the  union  of  broken  bones ;  and  only  exists  in 
cases  where  it  is  impossible  to  restrain  motion  in  the  frag- 
ments. The  accompanying  cut,  (Fig.  2),  from  a  specimen  in 
my  possession,  shows  that  in  the  union  of  fractured  ribs,  where 
respiration  keeps  up  constant  motion  of  the  fragments,  there 
is  not  only  a  large  amount  of  provisional  callus,  but  bridges 
of  bone  reaching  from  one  rib  to  another  along  the  course  of 
the  intercostal  muscles,  are  built  up  as  1C  to  support,  or  to 


PROCESS  OF  UNION. 


33 


steady,  the  moving  fragments.  I  have  another  specimen  from 
a  leg,  in  which  both  bones  were  broken  near  the  ankle,  and  a 
long,  curved  spur  of  new-made  bone  was  sent  backward  from 


Union  of  broken  ribs,  with  "bridges  ''  of  bone  in  the  coursf  of  the  interr-ostnl  muscles. 

the  tibia,  at  the  seat  of  fracture,  to  the  tendo  Achillis,  as  if  to 
gain  support  from  that  rather  stable  tendon.  The  excessive 
production  of  callus  thrown  out  in  the  repair  of  fractures  in 
the  neighborhood  of  joints,  especially  of  the  hip-joint,  is  a 
strengthening  buttress  pushed  out  to  give  stability  to  moving 
pai'ts. 

When  a  broken  bone  is  not  accompanied  with  much  injury 
to  the  surrounding  soft  tissues,  and  there  is  no  displacement ; 
and  when  the  fragments  are  steadily  held  in  place,  without 
motion  or  disturbance,  there  is  no  ring  or  ferule  of  reparative 
material  employed  in  the  union  ;  but  the  opposed  broken  sur- 
faces of  the  fragments  unite  without  ridge  or  outside  callus, 
by  a  process  akin  to  that  called  "  first  intention  "  in  wounds. 

It  is  still  a  question  whether  the  intervention  of  cartilagin- 
ous material  ever  exists,  or  is  necessary,  in  the  last  stages  or 
repair  in  broken  bones.  In  young  subjects  and  in  the  inferior 
animals  the  presence  of  cartilaginous  tissue  has  been  observed, 
but  as  there  are  numerous  instances  in  which  its  presence  is 
not  constant,  the  necessity  for  its  existence  is  questionable. 
In  adults  the  intervention  of  cartilage  is  exceedingly  rare ; 
and  union  without  any  perceptible  callus  is  the  rule,  and  not 
the  exception,  in  well  treated  cases. 

The  agency  of  granulations  in  the  repair  of  compound  frac- 
tures becomes  almost  a  necessity.  In  the  union  of  simple 
3 


34  FRACTURES. 

fractures,  especially  if  inflammation  be  restrained  within  ordi- 
nary ranges,  no  granulations  are  interposed. 

In  the  majority  of  cases  the  reparative  material  employed 
in  the  union  of  fractures,  is  similar  to  that  employed  for  the 
repair  of  soft  tissues  by  adhesion.  This  material  is  supplied 
from  the  vessels  of  the  surrounding  tissues,  and  by  those  of 
the  bone  and  of  the  periosteum.  The  vessels  of  the  medullary 
membrane  also  contribute  a  share  in  the  work  of  furnishing 
supplies.  If  the  fragments  be  kept  at  rest  and  in  strict  appo- 
sition, the  reparative  material  is  found  chiefly,  if  not  entirely, 
between  them.  When  from  irritation,  motion,  or  want  of 
apposition  between  the  fragments,  it  extends  outside  the 
broken  ends  of  the  bone,  it  gets  between  the  periosteum  and 
the  bone,  and  even  into  the  adjacent  tissues.  The  diagrams 
in  Paget's  Surgical  Pathology,  which  represent  the  periosteum 
as  having  been  separated  from  the  bone  to  allow,  as  it  weiv. 
room  for  the  "  ensheathing  "  callus,  may  faithfully  ropm-mr 
the  ideas  of  the  author,  but  they  do  not  represent  the  true 
healing  state.  The  reparative  material  gets  upon  the  outside 
or  external  surface  of  the  periosteum,  as  well  as  between  that 
membrane  and  the  bone.  The  reparative  material  extends 
into  the  medullary  cavity,  but  never  between  the  medullary 
membrane  and  the  bone. 

The  shaping  or  modelling  of  the  excess  of  reparative  mate- 
rials after  the  union  is  complete,  is  a  work  of  time.  All  rough 
and  unnecessary  projections  are  removed  by  absorption ;  the 
sharp  points  left  by  the  overlapping  of  ill-uniting  fractun-. 
whether  deep  or  superficial,  are  first  softened  by  the  disap- 
pearance of  their  earthy  matter,  and  subsequently  removed. 
and  the  rough  surfaces  rounded  off.  The  pressure  and  fric- 
tion of  the  muscles,  are  the  chief  agencies  in  the  work  of 
polishing  and  absorption. 

In  fragments  that  overlap,  a  hard  bony  cap  covers  the  ends 
of  the  fragments,  and  the  compact  walls  resting  against  one 
another,  (Fig.  3),  and  the  cancellous  tissue  of  both  communi- 
cate, the  new  connecting  material  being  more  vascular  and 
spongy  than  the  walls  of  the  old  bone. 

Although  the  dressings  can  generally  be  removed  with 
safety  in  from  four  to  six  weeks,  ossification  is  rarely  com- 
pleted before  the  ninth  or  tenth  Aveek  after  the  injury.  In  in- 
fants the  time  of  union  is  reduced  to  fifteen  or  eighteen  days ; 


PROCESS  OF  UNION. 


35 


Fio.  3. 


in  old  age  two  or  three  months  are  required  to  consolidate 
the  fragments.  If  the  fragments  overlap 
or  rest  faultily  with  one  another,  the  time 
of  reparation  is  greatly  retarded;  in  cases 
of  double  fracture,  in  which  it  is  difficult 
oc  impossible  to  prevent  riding,  the  work 
of  repair  is  always  tedious. 

Compound  fractures  require  about  three 
times  as  long  a  period  to  complete  the 
union  as  the  simple.  Fractures  from  gun- 
i  shot  wounds,  on  account  of  damage  to 
soft  parts,  and  the  comminution  of  the 
'  bone,  are  exceedingly  tedious  in  the  pro- 
cess of  cure.  When  there  has  been  ac- 
tual loss  of  bone,  as  by  the  removal  of 
splinters,  or  comminuted  portions,  the 
time  occupied,  in  the  restoration  is  very 
much  prolonged. 

A  fracture  extending  into  a  joint  is 
never  followed  by  reunion  of  the  articular 
cartilage.  The  bone  unites,  leaving  an  interval  between  the 
borders  of  the  cartilage,  which  may  or  may  not  till  with  fibrous 
tissue.  Sometimes  a  ridge  of  osseous  material  projects  into 
the  space  between  the  broken  cartilage,  which,  by  interfering 
with  the  functions  of  the  joint,  favors  anchylosis.  In  frac- 
tures penetrating  the  articulations,  the  synovia!  membrane  be- 
comes thickened  by  inflammation,  the  sheaths  of  passing  ten- 
dons get  blocked  up  with  effused  and  organized  plastic  lymph, 
so  that  considerable  stiffness,  if  not  genuine  anchylosis,  is 
likely  to  follow.  Passive  motion  after  the  bony  fragments 
have  united  with  osseous  material,  is  the  proper  method  ol 
restoring  the  functions  of  the  joint. 


Shows  uniting  medium  whore 
the  fragments  overlip. 


CHAPTER    IV. 
NON-UNION  OR  FALSE  JOINT  AFTER  FRACTURE. 


It  is  a  fortunate  circumstance  in  the  history  of  broken 
bones,  that  the  fragments  rarely  fail  to  unite  through  the 
medium  of  osseous  material.  The  process  of  union  may  be 
delayed  or  completely  arrested  at  any  period  of  its  progress. 
And  as  there  is  no  precise  time  when  consolidation  is  effected, 
a  tardy  union  should  not  be  looked  upon  as  evidence  of  a 
total  lack  of  uniting  capacity  between  the  fragments.  If 
there  be  no  bony  union  in  ten  or  twelve  weeks  after  fracture, 
the  surgeon  begins  to  grow  uneasy  in  regard  to  the  result,  and 
to  cast  about  for  the  cause  of  the  delay  or  inability. 

Certain  fractures  frequently  fail  to  unite  by  osseous  mate- 
rial. The  neck  of  the  femur,  within  the  capsular  ligament, 
seldom  unites  by  bony  union ;  the  patella,  from  the  fragments 
being  held  at  a  distance  apart  by  the  contraction  of  the  quad- 
riceps muscle,  often  makes  only  a  fibrous  connection  of  its 
fragments;  the  olecranon  and  the  coronoid  processes  of  the 
ulna  omit  the  osseous  union  for  a  similar  reason ;  the  condylcs 
of  the  humerus  occasionally  fail  to  effect  a  bony  consolidation 
with  the  shaft,  when  free  motion  is  not  restricted  by  a  proper 
dressing.  But  these  bones,  having  special  causes  for  failure 
to  unite,  do  not  come  so  particularly  under  consideration  in 
this  place. 

When  there  is  failure  to  unite  in  fractures  which  ordinarily 
consolidate  in  the  usual  time,  the  defect  may  be  regarded  as 
pseudarthrosis  from  extraordinary  causes.  In  such  cases  a 
soft  ligamentous  substance  remains  between  the  ends  of  the 
fragments,  and  shows  no  disposition  to  become  ossific.  In 
rare  instances  no  ligamentous  substance  is  formed.  The  ends 
of  the  fragments  become  smooth  and  rounded,  constituting  a 

(36) 


FALSE  JOINT  AFTER  FRACTURE.  37 

real  false  joint.  The  ends  of  the  bones  move  freely  against 
one  another,  being  retained  in  their  place  by  a  kind  of  cap- 
sule, which  is  lined  with  synovial  membrane. 

Ununited  fractures  are  so  exceedingly  rare  that  some  expe- 
rienced surgeons  never  met  with  a  case.  Lonsdale  found  but 
four  or  five  cases  out  of  four  thousand  fractures  treated  at 
Middlesex  Hospital,  London.  Listen  met  with  only  one  case 
in  his  OAvn  practice.  Hamilton  estimates  that  one  case  does 
not  occur  in  five  hundred  fractures.  According  to  JS"orris' 
tables,  the  humerus  and  the  femur  are  bones  most  liable  to 
non-union.  This  circumstance  goes  to  show  that  motion  has 
much  to  do  with  the  failure  to  unite.  When  the  tibia  alone 
is  broken,  it  rarely  fails  to  obtain  bony  union,  yet  after  a  frac- 
ture of  both  bones  of  the  leg,  false  joint  stands  next  in  fre- 
quency to  similar  defects  in  the  humerus  and  femur. 

The  constitutional  causes  of  non-union  include  all  those  con- 
ditions in  which  the  powers  of  the  system  are  much  impaired. 
Old  age,  pregnancy,  lactation,  syphilis,  scurvy,  and  especially 
the  extreme  debility  of  shattered  inebriates,  have  been  ob- 
served as  causes  retarding  osseous  union.  Patients  having  been 
subjected  to  courses  of  mercury,  and  other  prolonged  devital- 
izing treatment,  suffer  from  retarded  union  after  fractures, 
and  sometimes  wholly  fail  to  obtain  consolidation  of  their 
broken  bones.  Larrey  frequently  saw,  in  his  extensive  cam- 
paigns, cases  of  false-joint  that  he  attributed  to  poor  diet,  and 
kindred  causes.  Dropsical  subjects  suffer  from  pseudarthrosis, 
and  very  generally  from  retarded  union. 

The  local  causes  of  ligarnentous  connections  and  false-joint, 
are  numerous  and  varied.  Disease  of  the  bone,  the  presence 
of  a  foreign  substance,  separation  of  the  fragments,  and  motion, 
are  the  most  prominent.  Obstruction  to  the  circulation, 
whether  from  morbid  conditions,  or  tight  bandaging,  always- 
retard  and  may  prevent  bony  union.  Immovable  dressings, 
especially  if  applied  too  tightly,  obstruct  the  local  circulation 
and  delay  the  healing  processes.  A  tight  bandage,  made 
uncomfortable  by  the  use  of  anodyne,  refrigerant,  and  stim- 
ulating lotions,  prodiu-os  an  aincniic  condition  of  the  limb  that 
opposes  rapid  and  satisfactory  recoveries.  Consolidation  of 
the  fracture  is  arrested  by  a  faulty  application  of  the  bandage 
or  dressings.  I  have  seen  an  arm  above  the  elbow  bandaged 
so  tightly  that  the  hand  and  forearm  were  nearly  strangulated. 


38  FRACTURES. 

Such  a  radical  interference  with  the  nutrition  of  the  limb 
must  obstruct  or  wholly  arrest  the  reparative  action. 

The  appearance  of  a  fractured  limb  in  which  the  work  of 
repair  has  been  suspended,  is  peculiarly  striking.  The  wasted 
flesh,  the  scaly  and  dead  condition  of  the  cuticle,  the  puffy  or 
flabby  state  of  the  member,  are  always  observable,  and  indi- 
cate the  greatly  enfeebled  nutritive  action. 

Fatty  degeneration  in  a  limb  partial!}-  paralyzed,  though 
not  previously  mentioned  by  any  author,  is  a  cause  of  baffled 
reparation.  In  one  case  of  this  kind,  I  was  unable  to  establish 
a  bony  union  for  five  months.  Even  then  the  consolidation 
was  effected  with  such  imperfect  material  that  the  woman 
sustained  a  second  fracture  within  a  year.  She  died  of  gen- 
eral debility  in  a  few  months  after  the  second  accident,  and 
at  the  time  of  her  death  there  had  been  no  progress  in  the 
work  of  repair. 

To  repeat,  movement  of  the  fragments,  whether  due  to  the 
patients'  restlessness,  to  some  defect  in  the  apparatus  used,  or 
to  any  other  cause,  is  the  obstacle  which  most  directly  inter- 
feres with  union.  In  forty-four  cases  investigated  by  Norris. 
movement  of  the  broken  ends  was  clearly  made  out  in  twenty- 
two  and  strongly  suspected  in  several  others. 

Xumerous  measures  have  been  devised  for  the  cure  of 
pseudarthrosis.  If  there  be  a  constitutional  vice,  an  attempt 
should  be  made  to  correct  it,  or  so  modify  it  that  the  recupera- 
tive powers  of  the  system  may  he  sufficient  to  heal  the  broken 
bones.  The  local  means  devised  for  the  successful  man  a  ire  - 
ment  of  ununited  fracture,  are  numerous  and  varied;  but  the 
object  of  all  is  the  same,  namely,  to  excite  action  in  the  parts 
around  the  ends  of  the  fragments  and  to  make  them  throw 
out  material  proper  for  their  consolidation.  Blisters,  friction, 
rasping,  removal  of  the  fractured  ends,  setons,  drilling  of  the 
bones,  and  other  means  have  been  tried,  and  with  various  de- 
irives.  of  success.  Blisters  can  accomplish  but  little,  as  the 
effect  of  the  irritation  does  not  reach  deep  enough  ;  rubbing 
of  the  sluggish  fragments  roughly  together  may  arouse  a  new 
action  which  will  result  in  union  ;  the  opening  of  the  fracture. 
and  rasping  the  broken  ends  of  the  bone,  has  been  recom- 
mended, though  the  results  are  not  flattering;  excision  of  the 
rounded  and  polished  surfaces  lias  been  performed  with  suc- 
cess ;  the  seton  applied  by  passing  a  long  flat  needle,  armed 


FALSE  JOINT  AFTER  FRACTURE.  39 

with  a  skein  of  silk,  either  between  or  close  by  the  ends  of 
the  bone,  and  kept  there  till  sufficient  action  is  produced  in 
the  part  to  cause  the  adjacent  textures  to  be  excited  to  throw 
out  the  proper  reparative  material,  has  been  highly  recom- 
mended. 

Dressing  the  leg — in  the  event  of  the  non-union  being  in 
one  of  the  lower  extremities — with  a  firm  support  of  splints 
and  bandages,  and  putting  the  patient  on  crutches  to  exercise 
in  the  open  air,  is  an  excellent  method  of  improving  the  gen- 
eral health,  and  of  arousing  sufficient  action  in  the  limb  to 
start  or  re-establish  the  healing  process.  Bearing  some  weight 
upon  the  leg  produces  friction  between  the  fragments,  and 
promotes  vital  activity.  Exercise  on  crutches,  with  gentle  use 
of  the  fractured  leg,  might  remove  or  press  out  of  position  a 
piece  of  ligament,  muscle  or  other  soft  tissue  that  had  effected 
a  lodgement  between  the  fragments  of  bone. 

Drilling  the  bone  near  the  fracture  for  the  purpose  of  in- 
serting ivory  pegs,  around  which  a  silver  wire  or  hempen  cord 
fastens  the  fragments  in  contact,  has  succeeded  in  establishing 
a  union  in  a  few  instances ;  but  the  method  has  also  failed. 

The  late  Dr.  Brainard,  of  Chicago,  suspected  that  the  drill- 
ing accomplished  more  good  than  the  pegs  and  fastenings, 
therefore  he  tried  perforating  the  sluggish  fragments  at  their 
ends,  with  an  awl  or  perforator.  The  instrument  devised  by 
him  has  a  stock  that  admits  of  a  change  in  the  size  of  the 

FIG.  4. 


Brainard's  perforator  or  drill. 

drills,  though  that  is  a  complication  not  absolutely  necessary. 
His  directions  for  using  the  instrument  are  as  follows:  "In 
case  of  an  oblique  fracture,  or  one  with  overlapping,  the  skin 
is  perforated  with  the  instrument  at  such  a  point  as  to  enable 
it  to  be  carried  through  the  ends  of  the  fragments,  to  wound 
their  surfaces,  and  to  transfix  whatever  tissue  may  be  placed 
between  them.  After  having  transfixed  them  in  one  direc- 
tion, it  is  withdrawn  from  the  bone,  but  not  from  the  skin,  its 
direction  changed,  and  another  perforation  made,  and  this 
operation  is  repeated  as  often  as  may  be  desired."  T\vo  or 


40  FRACTURES. 

three  perforations,  according  to  Dr.  Brainard,  are  enough  to 
commence  with ;  more  may  be  tried  if  the  first  fail  to  accom- 
plish the  object  designed.  After  the  perforations  have  been 
made,  the  limb  should  be  dressed  as  in  a  recent  fracture,  and 
kept  at  rest  for  several  weeks  before  observations  are  made  to 
determine  whether  consolidation  has  commenced  or  perfected 
a  union.  Of  all  the  means  devised  and  recommended  for  the 
treatment  of  ununited  fractures,  the  plan  of  Dr.  Brainard  has 
been  attended  with  the  greatest  degree  of  success.  It  is  easy 
to  put  in  practice,  as  any  awl  or  drill  which  can  be  trusted  to 
perforate  bone,  wiU  answer  the  purpose.  The  .point  of  an  awTl 
which  makes  few  chips  is  preferable  to  others. 

^on-union  is  not  so  distressingly  inconvenient  as  might  be 
supposed.  In  the  leg  it  is  the  worst ;  but  even  there  a  heavy 
leather  apparatus,  with  side-irons,  or  a  mechanical  support  of 
some  kind,  can  be  worn,  which  will  enable  the  patient  to  walk 
tolerably  well.  In  the  arm,  the  functions  of  the  member  are 
generally  preserved  in  a  good  degree,  and  the  limb  is  not 
without  strength  and  general  usefulness. 

The  freshening  of  the  ends  of  the  fragments  can  be  accom- 
plished by  cutting  the  skin  and  tascias  over  the  fracture,  pull- 
ing the  edges  of  the  wound  apart  with  retractors  and  then 
cutting  off  the  smooth  extremities  of  bone  with  pliers;  even 
u  saw  can  be  used  in  the  freshening  process.  The  affair  is 
then  like  a  compound  fracture,  andean  he  treated  successfully 
with  a  firm  dressing.  It  the  tibia  be  the  subject  of  non-union 
the  foot  must  be  kept  flexed  on  the  leg  till  consolidation  is 
known  to  have  taken  place.  It  is  astonishing  how  much  can 
be  gained  by  strapping  the  foot  in  a  flexed  state  to  the  k-g 
above.  The  manoeuvre  can  be  accomplished  with  a  long  loop 
of  adhesive  plaster,  the  middle  going  under  the  ball  of  the 
foot  or  the  toes,  and  the  ends  extending  to  the  calf  of  the  leg. 


CHAPTER    \. 
DEFECTIVE    UNION 


Some  united  fractures  are  subject  to  frequent  and  long-con- 
tinued pain,  analogous  to  the  neuralgia  of  cicatrices  in  soft 
parts ;  others  are  kept  irritable  by  an  exuberance  of  callus 
which  piles  up  in  ridges  about  the  seat  of  injury. 

There  are  three  species  of  deformity  resulting  from  mal- 
union  :  Junction  with  permanent  displacement,  angular,  rota- 
tory, or  shortening ;  union  of  two  contiguous  bones,  as  of  the 
radius  and  ulna  ;  and  projection  of  one  of  the  fragments. 

Angular  deformity  can  sometimes  be  remedied  by  gradual 
compression.  This  may  be  applied  with  a  common  fracture 
apparatus,  and  by  mechanical  contrivances  suited  to  the  indi- 
vidual case.  A  splint  may  be  placed  opposite  the  concavity 
of  the  angle,  and  the  bone  drawn  toward  it ;  or  it  may  be  fixed 
to  one  fragment  on  the  convex  side,  and  perform  the  part  of 
a  lever  to  which  the  other  is  to  be  drawn  by  means  of  band- 
ages ;  or,  the  projecting  angle  may  be  pressed  between  two 
opposing  splints.  The  bandages  must  be  kept  tightened  in 
order  that  the  pressure  may  be  maintained.  The  pressure 
may  be  begun  as  late  as  five  or  six  weeks  after  the  fracture  is 
received,  and  be  kept  up  for  several  weeks.  Ordinary  exten- 
sion, combined  with  pressure,  aids  in  the  straightening  process. 

Re-fracture  has  been  resorted  to  in  cases  of  distorted  union. 
This  is  to  be  done  gradually  with  the  hands  and  the  knee,  and 
not  violently  with  a  mallet  or  quick  motion  across  the  edge 
of  a  board  or  bedstead. 

There  is  some  danger  of  breaking  the  bone  in  the  wrong 
place,  though  the  callus  generally  yields  in  preference  to  a  new 
place.  This  tendency  to  break  through  the  callus  arises  from 
the  fact  that  in  those  cases  requiring  refracture,  the  union  is 
apt  to  be  irregular  and  otherwise  faulty.  Refracture  is  not  to 


42  KKACTLUKS. 

be  attempted  in  a  consolidation  over  six  months  old.  The 
new  fracture  is  not  attended  with  a  deficiency  of  healing- 
power  ;  iu  many  cases  the  reparative  process  in  the  effort  at 
reunion,  seems  to  have  been  accelerated. 

After  the  union  of  two  contiguous  bones,  as  of  the  radius 
and  ulna,  an  attempt  to  effect  a  separation  of  parts  not  be- 
louging  together,  should  be  made  in  cases  promising  relief. 
A  patient  under  chloroform  does  not  suffer  from  the  force  the 
surgeon  applies.  An  assistant,  to  steady  the  shoulder  and 
elbow,  gives  the  surgeon  an  opportunity  to  exert  great  pro- 
nating  and  supinating  power  upon  the  arm. 

A  projecting  point  of  bone  at  the  seat  of  fracture,  is  gener- 
ally rectified  in  a  great  measure  by  the  ordinary  pressure  ot 
the  soft  tissues  upon  the  part.  In  very  objectionabl-e  instances 
the  salient  point  of  bone  maybe  cut  down  upon,  and  removal 
with  the  saw  or  bone  nippers. 

Chronic  pains  at  the  seat  of  fracture  may  be  modified  i>\ 
the  application   of  stimulating  liniments,  and  by  the  u- 
flannel  bandages.     Enlarged  capillaries  and  varicose  veins,  are 
also  relieved  by  the  bandaging. 

When  partial  anchylosis  takes  place  at  the  knee  or  elbow 
joints,  it  is  generally  good  surgery  to  put  the  patient  under 
the  influence  of  an  anaesthetic,  and  with  force  separate  the 
fortuitous  connections.  After  a  well  executed  operation  of 
this  kind,  passive  motion  should  be  kept  up  for  several  \veek> 
m  order  to  thwart  attempts  at  re-union,  and  to  favor  a  resto- 
ration of  the  functions  of  the  joint.  In  cases  of  anchylosis, 
if  recent,  and  free  from  other  complications,  an  attempt  to 
regain  motion  is  seldom  attended  with  harm,  and  is  often  fol- 
lowed with  happy  results.  However,  little  good  will  be  ac- 
complished unless  passive  motion  be  brought  to  bear  several 
times  a  day  for  weeks  aud  even  months.  I  have  made  sati»- 
factory  gains  in  lessening  anchylosis  after  six  months  have 
elapsed.  Nature  is  ready  to  favor  any  efforts  directed  to  the 
perfection  of  her  plans  or  tendencies. 


CHAPTER    VI. 


GENERAL  REMARKS  IN  REGARD  TO   THE  TREATMENT 
OF  FRACTURES. 


The  treatment  of  fractures  consists  in  reducing  the  broken 
ends  of  bone  to  direct  apposition,  and  in  keeping  them  in  place 
until  consolidation  is  effected.  There  are  some  cases  in  which 
there  is  no  call  for  reduction,  the  relative  position  of  the  frag- 
ments being  unchanged' by  the  accident.  In  such  instances 
tin-  surgeon  has  only  to  maintain  the  parts  involved  in  the  in- 
jury, at  rest,  and  to  guard  against  displacement. 

These  general  statements  render  the  subject  apparently 
simple,  for  they  make  no  allusion  to  the  various  complications 
which  render  this  branch  of  surgery  one  of  great  responsibility. 
In  the  ordinary  discharge  of  those  professional  duties  which 
fall  to  the  lot  of  the  country  practitioner  of  medicine  and 
surgery,  there  are  none  so  trying  and  difficult  to  perform  suc- 
cessfully as  those  pertaining  to  the  management  of  broken 
bones.  The  inexperienced  physician  may  avoid  performing 
what  are  ordinarily  considered  surgical  operations,  but  if 
called  to  a  fracture  he  does  not  feel  like  shirking  the  respon- 
sibilities of  the  case.  A  medical  man  would  lose  caste,  and 
be  considered  timid,  if  he  should  decline  to  take  charge  of  a 
fracture,  though  he  knows  that  the  public  holds  him  pecuni- 
arily responsible  for  the  result  of  the  treatment,  There  is  a 
wrong  sentiment  in  every  community  in  regard  to  the  dutie> 
and  responsibilities  of  a  physician,  called  to  take  charge  of 
fractures.  The  medical  practitioner  has  a  right  to  decline  any 
case  he  pleases  on  the  ground  of  inexperience  on  his  part. 

It  is  not  absolutely  necessary  that  a  fracture  be  "  set "  the 
very  hour  it  is  received.  The  patient  can  be  made  compara- 
tively comfortable  until  the  services  of  an  experienced  sur- 
geon, who  is  willing  to  assume  the  responsibilities  of  the  case, 

(43) 


44  FRACTURES. 

can  be  secured.  The  people  should  be  made  to  un-.  <tand 
that  a  fractured  bone  needs,  for  its  skillful  manageme.  t,  the 
highest  order  of  surgical  ability.  A  man  maimed  or  «amed 
for  life  by  a  crooked  or  shortened  limb,  is  often  a  striking  ex- 
hibition of  professional  incompetency.  The  victim  of  a  blun- 
deringly prescribed  dose  of  medicine  may  go  to  the  grave  and 
be  forever  unseen,  or  fortunately  recover,  bearing  no  evidence 
of  malpractice,  but  a  bad  piece  of  surgery  follows  the  author 
of  it  like  "  a  shadow,"  reminding  him  of  inattention  and  in- 
discretion. 

It  is  not  to  be  understood  that  a  competent  surgeon  never 
has  any  unfortunate  cases ;  very  far  from  it.  Even  the  most 
experienced  are  charged  with  malpractice,  and  sometimes 
justly.  If  a  young  practitioner  expects  to  treat  fractures, 
he  should  spare  no  pains  to  thoroughly  inform  himself  upon 
all  such  injuries,  and  especially  upon  those  that  are  oftenest 
followed  by  defects  and  deformities  leading  to  malpractice 
suits.  He  should  study  the  nature  of  rotation  in  the  forearm, 
and  the  causes  that  lead  to  its  arrest  in  the  treatment  of  frac- 
tures of  the  radius  and  ulna  ;  he  will  learn  the  necessity  of 
being  guarded  in  his  prognosis  when  about  to  engage  in  the 
treatment  of  a  fracture  of  a  condyle ;  he  must  not  be  too  cer- 
tain of  a  fortunate  result  in  fractures  of  the  shaft  of  the 
femur,  though  the  nature  of  the  injury  be  very  plain;  over- 
lapping and  consequent  shortening  will  have  to  be  battled  all 
through  the  healing  process  ;  in  a  plain  fracture  of  the  tibia, 
he  is  not  to  be  satisfied  that  the  diagnosis  is  complete  till  the 
fibula,  its  whole  length,  has  been  carefully  examined  and  pro- 
nounced intact;  finally,  he  is  to  master  that  frequent  in- 
jury, fracture  of  the  fibula  just  above  the  malleolus,  Compli- 
cated with  dislocation  of  the  tibio-tarsal  articulation. 

In  the  management  of  surgical  cases  the  physician  is  held 
responsible  for  an  average  result.  In  other  words,  he  must  ex- 
hibit as  much  skill  and  attention  as  are  ordinarilij  displayed 
by  the  profession  at  large.  The  term  "ordinarily,"  as  nsi-d 
in  this  connection,  is  susceptible  of  no  precise  or  inflexible 
definition  ;  hence  there  must  always  be  difficulty  in  applying 
its  import  or  meaning  in  every  case. 

In  a  rural  district,  where  opportunities  for  treating  and  ob- 
serving surgical  cases  are  necessarily  limited,  a  less  degree  of 
skill  must  pass  as  ordinary,  than  in  cities  and  largo  towns 


GENERAL  REMARKS.  45 

tvhere  exist  greater  facilities  for  observation  and  experimental 
knowledge.  Besides,  the  country  practitioner  is  not  expected 
or  required  to  have  at  hand  for  all  emergencies,  the  most  novel 
instruments  and  appliances  ;  or  to  leave  his  business  and  spend 
time  and  money  in  seeking  them, granting  that  he  knows  what 
is  best  or  most  approved,  if  the  physician  exercises  ordinary 
skill,  care  and  caution,  and  makes  good  use  of  materials  within 
reach,  or  manages  the  case  well,  taking  all  circumstances  into 
consideration,  he  is  not  pecuniarily  liable  for  an  unfortunate 
result.  This  is  not  written  as  an  apology  or  excuse  for  igno- 
rance, blundering  and  inattention,  which  are  never  pardonable, 
but  to  place  the  question  of  pecuniary  responsibility  in  the 
light  in  which  it  is  held  by  the  courts. 

If  medical  men  were  to  be  held  strictly  accountable  for  the 
results  of  injuries  and  surgical  operations,  few  practitioners 
would  hazard  their  reputation  and  property  in  cases  involving' 
the  dangers  of  alleged  inalpractice.  Patients  would  call  in 
vain  for  surgical  aid  at  a  time  when  professional  services  might 
be  of  vital  importance. 

FIRST   ATTENTIONS   TO   THE   PATIENT. 

A  person  with  a  fracture  of  the  upper  extremity,  can  sup- 
port the  injured  member  with  the  sound  hand,  and  seek  a 
surgeon  himself,  or  go  home,  and  have  one  summoned  to  his 
assistance.  A  patient  will  carry  his  own  broken  arm  with 
more  steadiness  than  any  assistant.  Walking  producss  less 
motion  between  the  fragments,  than  riding. 

When  a  fracture  occurs  to  the  bones  of  tlie  leg  or  to  the 
femur,  the  patient  is  not  able  to  walk.  The  pain  attendant 
upon  being  removed  home  from  the  place  of  accident,  is  often 
intolerable.  The  following  is  the  language  of  that  famous 
surgeon,  Ambrose  Fare,  who,  just  as  he  was  going  on  board  a 
boat,  had  his  left  leg  broken  by  the  kick  of  a  horse  :  "  Having 
received  the  blow,  and  dreading  lest  the  horse  should  repeat 
it,  I  made  a  step  backward  ;  but  suddenly  falling  to  the 
ground,  the  broken  bones  stuck  out,  piercing  the  ilesh,  the 
stocking,  and  the  boot ;  from  which  1  felt  the  most  intolerable 
pain.  Very  soon  I  was  carried  to  the  boat,  to  be  taken  to 
the  other  side,  that  I  might  be  dressed.  But  the  jolting  thus 
caused  nearly  killed  me,  since  the  broken  ends  of  the  bones 
tore  the  flesh,  and  those  who  bore  me  were  unable  to  fix  them, 


46  FRACTURES. 

On  landing  I  was  carried  to  a  house  in  a  village,  with  even 
-•reater  suffering  than  I  had  endured  in  the  boat ;  for  one  car- 
ried my  body,  another  my  leg,  and  another  my  foot;  and  in 
walking  along  they  did  not  keep  in  step.  At  length,  how- 
ever, I  was  laid  on  a  bed  to  take  breath  ;  and  here,  while  the 
dressings  were  in  preparation,  I  found  myself  in  perspiration 
all  over;  had  I  been  plunged  in  water  I  should  not  have  been 
more  thoroughly  wetted."  The  great  surgeon,  Percival  Pott, 
luid  a  similar  experience  to  that  of  Pare.  Falling  from  a 
horse  in  Southwark,  in  the  suburbs  of  London,  he  broke  his 
leg,  and  the  jagged  end  of  the  bone  pierced  the  skin.  Esti- 
mating the  suffering  he  would  undergo  if  carried  home  in  a 
carriage,  he  sent  for  men,  and  some  poles  suitable  for  support- 
ing his  body.  He  purchased  a  door,  and  made  the  men  nail 
the  poles  to  it;  once  mounted  upon  this  improvised  litter,  he 
rode  home  in  comparative  comfort,  though  his  sufferings  alto- 
gether were  intense.  . 

A  door  or  shutter  taken  from  its  hinges, constitutes  a  ready 
litter,  upon  which  a  patient  with  a  broken  leg  can  ride  home 
without  serious  jolting.  A  carriage  is  difficult  of  ingress  and 
egress;  a  wagon,  with  its  bottom  covered  with  straw  or  a  bed, 
is  a  pretty  good  ambulance,  and  is  oftener  employed  than  any 
other  means  of  transportation. 

The  patient  having  been  brought  near  the  bed,  the  clothing 
should  be  carefully  removed.  While  the  broken  leg  is 
steadied,  the  seam  of  pants  is  ripped  the  whole  length,  so  the 
garment  can  be  removed  without  difficulty.  The  patient  is 
now  ready  to  take  the  bed,  and  to  have  the  limb  dressed. 

POSITION   A   FRACTURED   LIMB  SHOULD   TAKE. 

A  great  deal  of  discussion  has  arisen  among  surgeons  in 
regard  to  the  position  a  limb  should  take  in  order  to  assist  in 
the  reduction  of  the  fracture,  and  to  facilitate  the  healing 
process. 

In  fractures  of  the  upper  extremity,  it  is  almost  invariably 
the  custom  to  keep  the  elbow  at  a  right  angle,  the  forearm 
being  supported  in  a  sling.  There  is  but  one  exception  to 
this  rule,  and  that  is  in  fracture  of  the  olecranon.  In  this 
particular  lesion  the  arm  must  be  kept  fully  extended  to  relax 
the  triceps,  and  to  favor  apposition  of  the  fragments. 


GENERAL  REMARKS  47 

In  the  lower  extremities  the  attitude  of  partial  flexion  is 
that  admitting  of  comfortable  repose.  Pott  claimed  that 
from  the  muscles  arises  the  whole  difficulty  of  reduction — the 
resistance  depending  upon  the  position  of  the  limb,  by  putting 
them  in  a  state  of  tension.  To  avoid  this  tension  the  limb 
should  be  so  placed  as  to  relax  the  muscles,  that  they  may  offer 
the  least  possible  resistance.  Such  a  position  is  that  of  semi- 
flexion. 

Desault  took  an  opposite  view.  He  contended  that  in  semi- 
flexion  there  is  difficulty  in  making  the  necessary  extension 
on  the  broken  bone;  that  in  such  a  position  there  is  an  im- 
possibility of  accurately  comparing  the  two  limbs;  that  it 
favors  derangements  of  the  fracture  while  the  patient  has  a 
movement  of  the  bowels.  He  also  urged  the  impracticability 
of  firmly  fixing  the  leg  in  a  flexed  position;  and  the  trouble 
of  adopting  this  method  when  both  limbs  were  broken;  and, 
lastly,  the  results  of  experience  were  against  it.  Bichat  as- 
serted that  what  was  gained  by  relaxing  one  set  of  muscles, 
was  lost  by  the  tension  of  others. 

Dupuytren,  in  reviewing  the  subject,  announced  that  while 
extreme  flexion  would  stretch  the  extensors,  and  complete  ex- 
tension made  tense  the  flexors,  partial  flexion  was  a  position 
of  ease,  which  is  the  best  condition  for  reduction. 

Malgaigne  asserts  that  experiments  made  upon  the  dead 
subject  could  not  settle  the  question  of  the  most  desirable 
attitude,  for  the  cadaveric  rigidity  is  quite  different  from  vital 
contractions.  "  Muscular  action  can  not  be  studied  except 
where  it  exists;  hence  experiments  must  be  made  of  necessity 
upon  the  living  subject."  He  alleges  that  complete  extension, 
like  complete  flexion,  is  a  fatiguing  and  painful  position  when 
kept  up  a  long  time. 

Boyer  says  :  "  Sometimes  the  difficulty  of  the  'reduction 
arises  from  the  forced  extension  of  the  limb  and  the  unequal 
stretching  of  the  muscles  ;  it  may  be  obviated  by  putting  the 
limb  in  a  state  of  semiflexion." 

A  patient  with  a  fractured  leg  which  confines  him  to  the 
horizontal  position,  can  be  attended  with  the  least  trouble  if 
he  be  placed  on  a  narrow  bed,  a  mattress  of  cotton  or  hair 
being  used  instead  of  feathers.  A  number  of  pillows,  to 
cushion  and  support  aching  and  uneasy  parts,  can  be  put  to 
good  use.  Bags,  holding  a  peck  or  more,  made  of  strong  cloth 


48  FllACTURES. 

or  drilling,  and  filled  with  nice  dry  sand,  are  exceedingly  use- 
ful to  put  under  the  knee,  if  semiflexion  be  adopted,  or  to 
bolster  the  limb  at  any  point.  Several  of  these  sand-bag  sup- 
ports may  be  needed  to  wedge  up  the  trochanters,  and  to  pre- 
vent the  limb  from  becoming  everted.  The  heel  which  grows 
restive  under  pressure,  is  generally  put  at  ease  between  two 
small  sand-bags. 

The  weight  of  heavy  bed  clothes  can  be  kept  from  the  foot 
and  limb,  by  means  of  hoops  taken  from  a  keg.  Two  half 
hoops  can  be  fastened  in  the  middle,  and  then  twisted  a  little 
from  one  another  at  their  free  ends,  so  as  to  form  a  four-legged 
screen  for  the  foot,  knee,  or  other  part  of  the  limb. 

To  prevent  the  trunk  from  sliding  down  the  bed,  a  perineal 
band  may  be  used.  This  can  be  fastened  to  the  head  of  the 
bed,  and  be  made  to  serve  as  counter-extension,  to  oppose 
ordinary  extension,  which  is  made  downward  from  the  knee, 
leg,  or  foot.  A  firm  piece  of  buckskin  forms  the  best  perineal 
band.  It  is  soft,  unirritating,  and  strong.  A  belt  of  drilling 
or  firm  muslin,  padded  to  prevent  irritation  at  points  of  pres- 
sure, will  answer  the  purpose. 

The  elevation  of  the  foot  of  the  bed  by  placing  blocks  or 
bricks  under  the  foot-posts,  is  a  method  of  getting  up  coun- 
ter-extension, now  considerably  in  use.  The  extending  strips 
or  apparatus  for  extension,  being  made  fast  to  the  foot-board, 
the  inclination  of  the  body  toward  the  head  of  the  bed,  is  a 
simple  manner  of  accomplishing  what  otherwise  would  require 
a  perineal  band,  and  other  disagreeable  and  complicated  ma- 
chinery. This  plan  was  devised  by  Dr.  Van  Ingen,  of  Sche- 
nectady,  iJ.  Y.  He  called  it  the  "  Natural  extension."  To 
avoid  unpleasant  sensations  from  having  the  head  too  low, 
high  pillows  may  be  used.  The  elevation  of  the  foot  tends 
to  prevent  oedema  and  congestion  of  the  limb. 


CHAPTER    VII. 

REDUCTION  OF  DISPLACED  FRAGMENTS. 


Before  any  efforts  are  made  to  reduce  or  adjust  the  dis- 
placed fragments,  it  is  best  to  prepare  and  have  at  hand, 
splints,  bandages,  compresses,  and  such  appliances  as  may  be 
needed  in  the  dressing.  Every  effort  to  pull  and  squeeze  a 
fractured  limb,  is  attended  with  intense  pain  ;  and  repetitions 
of  purposeless  manipulations  may  do  harm  to  the  parts  in- 
volved in  the  injury. 

Everything  being  ready  for  the  dressing,  the  reduction  may 
be  made,  if  any  be  required.  In  many  instances  there  is  no 
displacement,  consequently  no  reduction  is  requisite.  Inex- 
perienced practitioners  give  every  limb,  before  they  place  it 
in  a  fracture  apparatus,  an  energetic  pulling,  and  not  a  few 
vigorous  twists,  to  reduce,  perhaps,  what  does  not  need  reduc- 
ing. It  is  folly  to  suppose  that  the  extent,  direction,  and  dis- 
placement of  every  fracture  can  be  accurately  determined  by 
an  examination.  The  depth  of  the  fractured  bone,  and  the 
swelling  of  the  soft  parts,  may  preclude  a  satisfactory  diag- 
nosis. The  usual  signs  of  fracture  having  been  observed,  and 
comparisons  made  with  the  other  limb,  the  existence  of  dis- 
placement can  be  pretty  accurately  determined.  Shortening 
or  overlapping  of  fragments  can  generally  be  overcome  by 
extending  and  counter-extending  forces  applied  by  the  hands 
of  assistants.  In  obstinate  cases  of  muscular  contraction, 
chloroform  may  be  used  to  overcome  it,  and  to  put  the  patient 
into  that  insensible  condition  which  admits  of  free  manipula- 
tion and  examination  of  injured  parts. 

As  soon  as  sufficient  extension  has  been  made  to  overcome 
the  resistance  of  the  muscles,  the  ends  of  the  broken  bone 
are  to  be  placed  as  nearly  as  possible  in  their  natural  relations. 
4  (49) 


50  FRACTURES. 

This  is  called  adjusting,  setting,  or  coaptating  the  broken 
bones;  and  is  generally  supposed  to  be  a  very  skillful 
manoeuvre,  though  not  halt'  so  difficult  to  perform,  as  to  keep 
the  bones  in  place  when  once  adjusted. 

In  fractures  of  subcutaneous  bones  it  is  generally  easy  to 
see  when  the  extension  is  sufficient,  and  the  coaptation  per- 
fect. The  sudden  restoration  of  the  natural  outline  of  the 
limb  is  pretty  good  evidence  of  the  mutual  adaptation  of  the 
fragments.  Measurements  and  comparisons  with  the  opposite 
limb,  afford  valuable  aid  in  determining  the  relations  of  the 
fragments ;  and  are  decisive  when  other  evidences  of  reduc- 
tion fail. 

In  the  event  of  a  serrated  or  impacted  fracture,  it  is  in- 
sary  to  extend  the  limb  beyond  its  natural  length,  and  then, 
by  partial  rotation,  to    coax   the  fragments  into  apposition. 
If  soft  parts  intervene  between   the  fragments,  they  are  gen- 
erally released  by  extension  and  rotatory  manoeuvres. 

As  a  general  rule,  the  sooner  reduction  is  effected  after  the 
accident,  the  better.  Some  surgeons  recommend  that  the  re- 
duction be  delayed  for  three  or  four,  or  even  ten  or  twelve 
days,  or  until  inflammation  has  subsided.  ]S*o  reparative  pro- 
cess of  a  substantial  nature  being  yet  commenced,  the  position 
of  the  fragments  during  that  period  does  not  interfere  with 
the  delayed  reduction,  nor  affect  the  final  result.  However, 
immediate  reduction  has  great  advantages.  It  restores  the 
patient  to  comparative  comfort,  and  diminishes  the  dangers  of 
spasmodic  twitchings  and  other  evils  resulting  from  the  mal- 
position of  the  parts. 

When  reduction  is  delayed  for  several  days  after  the  acci- 
dent, the  fragments  become  more  or  less  fixed  by  effusions  into 
the  surrounding  tissues ;  and  the  muscles,  accustomed  to  a  new 
position,  offer  considerable  resistance  to  a  change. 

If  the  surgeon  is  not  called  for  three  or  four  days  after  the 
reception  of  the  injury,  or  until  the  inflammation  is  at  its 
height,  it  may  be  advisable  for  the  time  to  use  such  remedies 
as  tend  to  lessen  the  inflammatory  action,  and  to  put  off  the 
reduction  until  the  parts  are  more  manageable.  The  disturb- 
ance of  an  irritable  injury,  when  much  inflammation  and  ex- 
cessive ecchymosis  exist,  has  provoked  convulsions,  uncontrol- 
lable twitchings,  and  even  tetanus.  On  the  other  hand,  ac- 
cording to  Yelpeau,  neither  inflammation,  nor  spasm,  should 


REDUCTION  OF  DISPLACED  FRAGMENTS.  51 

induce  any  delay;  so  far  from  that,  immediate  reduction  is  the 
quickest  and  surest  method  of  alleviating  them. 

Malgaigne  declares  that,  on  account  of  muscular  contrac- 
tion and  spasm,  he  has  been  frequently  thwarted  in  his  efforts 
at  reduction,  even  with  good  assistants,  and  therefore  has  been 
obliged  to  resort  to  mechanical  means  to  multiply  force.  As 
he  says  nothing  about  the  relaxing  effects  of  chloroform,  it  is 
probable  that  he  did  not  use  the  agent.  Under  the  influence 
of  profound  anaesthesia,  few  patients  will  be  met  whose  mus- 
cular condition  can  resist  well  directed  efforts  at  reduction. 

Several  surgeons  have  been  obliged  to  saw  off  the  protrud- 
ing fragment  in  compound  fracture,  before  a  reduction  could 
be  effected.  Cases  treated  in  that  manner  have  been  reported 
as  doing  well,  union  taking  place  as  readily  as  in  ordinary 
compound  fracture.  Of  course,  there  would  be  as  much  short- 
ening as  there  was  length  of  bone  removed,  yet  that  would 
be  moderate  in  most  instances. 

In  managing  a  compound  fracture  the  finger  is  to  be  em- 
ployed to  ascertain  if  there  be  present  in  the  flesh  detached 
pieces  of  bone  that  need  removing.  To  leave  such  pieces 
would  endanger  non-union,  prolonged  suppuration,  and  other 
serious  troubles.  When  a  fragment  of  bone  protrudes  through 
a  wound  in  the  flesh,  it  is  best  to  enlarge  the  aperture  in  the 
integument,  in  order  to  secure  reduction.  A  laro;e  wound  in 

^J  O 

the  skin  heals  about  as  quickly  as  a  small  one.  Besides,  an 
opening  of  considerable  size  the  more  readily  admits  explo- 
rations with  the  forefinger.  And  if  detached  fragments,  that 
may  perish,  be  present,  the  external  wound  offers  an  excellent 
opportunity  to  extract  them.  In  a  comminuted  fracture  the 
opening  made  in  the  flesh  is  indispensable  to  a  right  under- 
standing of  the  situation  of  affairs. 


CHAPTER    VIII. 
APPARATUS  FOR  THE  TREATMENT  OF  FRACTURES. 


Much  ingenuity  has  been  displayed  in  the  invention  and 
construction  of  apparatus  for  treating  fractured  bones.  The 
apparatus  for  retention  includes  bandages,  splints,  junks,  me- 
chanical contrivances  for  maintaining  extension,  immovable 
dressings,  together  with  belts,  adhesive  plaster,  woven  wire. 
and  various  means  to  euable  the  surgeon  to  manage  special 
cases. 

Bandages,  or  rollers,  as  they  are  sometimes  called,  can  be 
made  of  several  different  materials.  Those  most  commonly 
used  are  made  of  old  sheets,  or  unbleached  muslin.  Flannel 
makes  an  excellent  bandage.  It  is  elastic,  and  does  not  slide, 
one  fold  over  another,  as  freely  as  cotton  fabrics. 

An  arm-bandage  should  be  at  least  two  inches  wide,  and 
eight  yards  long;  a  leg-bandage,  two  and  a  half  inches  wide 
and  ten  yards  long;  and  a  rib-bandage,  five  inches  wide  and 
twelve  yards  long.  There  is  no  inflexible  rule  governing  the 
dimensions  of  bandages,  yet  it  is  of  considerable  importance 
that  the  width  and  length  of  a  bandage  be  properly  adapted 
to  the  part  to  be  treated.  A  bandage  which  is  to  extend  from 
the  hand  to  the  elbow,  or  from  the  foot  to  the  knee,  need  not 
be  so  long  as  indicated  above.  A  bandage  should  be  cut  off 
as  soon  as  enough  has  been  used  ;  no  advantage  is  gained  by 
making  more  turns  than  are  necessary. 

All  bandages  should  be  rolled  into  a  firm,  even,  and  com- 
pact mass.  This  may  be  done  perfectly  well  with  the  hands, 
or  upon  the  knee,  after  the  roll  is  started.  An  assistant  may 
take  the  kinks  and  twists  out  of  the  strip  as  it  is  being  rolled. 

A  bandage  which  is  used  with  plaster  of  Paris,  to  constitute 
an  immovable  dressing,  ought  to  be  made  of  coarse  muslin,  so 
as  to  retain  the  gypsum  in  its  meshes. 

(52) 


APPAKATUS  FOR  FRACTURES. 


53 


As  far  as  practicable,  the  bandage  ought  to  be  made  of  one 
continuous  piece,  or  with  few  joinings;  and  the  selvedges 
should  always  be  torn  off.  In  a  word,  the  surfaces  and  edges 
of  the  bandage  ought  to  be  as  smooth  and  even  as  they  can 
be  made ;  and  there  should  be  nothing  which  can  press  un- 
equally upon  the  limb,  to  constrict  or  irritate  it  in  any  way. 

In  applying  a  roller  it  is  desirable  to  secure  the  end  of  the 
bandage  by  the  first  turn  or  two,  in  order  that  the  proper  trac- 
tion may  be  sustained  without  slipping.  A  turn  is  generally 
taken  around  the  wrist  or  ankle  for  no  other  purpose  but  to 
fix  the  commencement  of  the  bandage. 


FIG.  5. 


Method  of  makiog  a  "reverse  "  in  a  spiral  reversed  bandage. 


When  a  bandage  is  to  rest  in  contact  with  the  skin,  it 
should  be  applied  flatly  to  the  surface — there  should  be  no 
creases  nor  puckers.  Where  the  part  to  be  bandaged  is  of 
nearly  uniform  calibre,  as,  for  example,  the  forearm  a  short 
distance  above  the  wrist,  the  roller  maybe  carried  around  the 


54  FRACTURES. 

limb  circularly,  forming'  what  is  called  a  "spiral  bandage." 
Kadi  turn  of  the  roller  ought  to  overlap  about  a  third  of  the 
preceding  one,  and  no  intervals  or  gaps  be  left  between  the 
turns.  But  the  conical  outlines  of  the  human  limbs  do  not 
readily  admit  of  the  simple  application  of  the  circular  bandage. 
It  becomes  necessary,  therefore,  to  apply  the  roller  by  making 
"  reverses,"  (Fig.  5),  or  to  adopt  some  other  plan  suited  to  the 
eontour  of  the  limb.  It  is  not  easy  to  describe  in  words  the 
method  of  making  "  reverses,"  but  the  accompanying  illus- 
tration shows  how  they  are  made. 

in  a  fracture  dressing  it  often  becomes  necessary,  in  order 
to  exert  a  considerable  degree  of  pressure  on  a  particular 
point,  to  place  a  wad  of  lint  or  folded  cloth,  called  a  compres-. 
underneath  the  bandage.  The  pad  or  compress  is  to  be  of  a 
size  and  shape  to  fit  or  suit  the  part  pressed  upon  ;  and  some 
care  must  be  exercised  to  confine  the  compress  to  the  spot 
where  the  extra  pressure  is  needed. 

When  the  arm  is  bandaged,  the  limb  should  be  coveivd 
from  the  fingers  upward  to  the  elbow  or  shoulder ;  and  the 
leg,  when  properly  bandaged,  is  covered  from  the  toes  upward 
to  the  knee  or  hip.  This  will  prevent  the  hand  or  foot  from 
becoming  swollen  and  cedematous. 

When  a  bandage  is  used  to  give  support  or  to  make  pres- 
sure, great  care  should  be  taken  that  it  is  not  so  tight  in  any 
part  as  to  cause  constriction.  Cases  are  on  record  in  which 
the  most  disastrous  results  have  been  brought  about  by  a  ban- 
dage being  drawn  too  tightly.  Limbs  have  sloughed  exten- 
sively, or  become  mortified,  requiring  immediate  amputation, 
for  no  other  reason  than  that  the  bandage  which  was  intended 
to  give  even  and  gentle  support,  has  been  applied  with  so 
much  pressure  as  to  stop  the  circulation,  and  to  establish  gan- 
grene. 

It  is  the  duty  of  the  surgeon  to  dress  a  fractured  limb  for 
the  first  time  as  if  he  expected  it  to  swell.  This  may  save 
him  the  trouble  of  being  called  to  loosen  the  bandage,  and 
the  patient  a  great  amount  of  needless  suffering. 

As  a  general  rule,abandage  ought  not  to  be  applied  under- 
neath a  splint.  The  splint  should  be  well  padded  with  raw 
cotton,  tow,  or  soft  cloth,  then  wound  with  strips  of  muslin, 
and  laid  next  the  skin. 


BANDAGES.  55 

MANY-TAILED  BANDAGE. — This  is  made  of  strips  long  enough 
to  go  once  and  a  half  around  the  limb.     These,  to  the  num- 
ber of  fifteen  or  twenty,  may  be  laid, before   application,  in 
regular  order,  from  above  downward,   one  overlapping   the 
other  for  about  a  third  of  its  width.     The  strips  may  be  kept 
in  their  places  by  a  longitudinal  band,  stitched  to  their  centre. 
When  the  bandage  has  been  prepared, 
the  limb  is  laid  upon  it,  or  the  strips, 
arranged  upon  apiece  of  pasteboard,  are 
slipped  under  the  limb  ;  and  then  each 
separate  piece  is  made  to  encircle  the 

\  ~~i7i  limb,  beginning  with  the  lowest,  the  ends 

being  brought  up,  one  on  each  side,  and 


V 


7 


crossed  in  front.  One  end  of  the  last  piece 

Bandage  of   strips,   or  many- 


£ 

'tailed  bandage.  only  needs  pinning ;  the  others  are  held 

by  the  overlapping.  This  has  been  called  the  bandage  of 
Scultetns,  and  is  convenient  in  compound  fractures,  as  the 
lacerated  tissues  can  be  examined  without  disturbing  the  limb 
the  ends  of  the  bandage  being  laid  off  for  the  time,  and  then 
returned  to  their  places. 

Another  similar  bandage  is  made  by  taking  a  piece  of  cloth 
long  and  broad  enough  to  envelop  the  limb,  and  tearing  it  on 
each  side  into  tails,  leaving  a  few  inches  in  the  middle  untorn, 
to  support  the  tails  or  strips.  The  ends  are  brought  around 
the  limb,  and  lapped,  as  in  the  bandage  of  Scultetus. 


BANDAGES  PREPARED    WITH   STARCH,  ETC. 


What  is  called  an  "  immovable  apparatus,"  is  generally 
made  by  saturating  the  bandages  surrounding  the  limb  with 
a  liquid  which,  after  it  is  dry,  gives  a  great  degree  of  solidity 
to  the  dressing.  By  means  of  this  the  patient  is  sometimes 
enabled  to  leave  his  bed  in  a  few  days  after  he  has  met  with 
a  fracture  of  the  leg,  or  even  of  the  thigh,  and  to  go  about  on 
crutches  during  the  time  that  union  is  taking  place. 

The  starch-bandage  may  be  made  as  follows  :  The  starch  is 
mixed  with  water  until  it  forms  a  thick  paste.  The  surgeon, 


56  FRACTURES. 

having  at  hand  rollers,  lint,  strips  of  pasteboard,  and  the  hasin 
of  paste,  lays  a  piece  of  broad  tape  along  the  front  surface  of 
the  space  to  be  bandaged,  (for  a  purpose  to  be  presently  ex- 
plained), and  then  begins  the  application  of  the  dressing.  A 
common  roller,  made  of  muslin  or  flannel,  is  run  upon  the 
broken  part,  whether  foot,  ankle,  leg,  or  thigh,  and  an  assist- 
ant, with  a  brush  or  swab,  applies  the  starch-paste  to  the  ban- 
dage as  it  goes  On.  Strips  of  pasteboard,  leather,  or  other 
bracing  material,  are*  dipped  in  the  paste,  and  then  laid  along 
the  limb  upon  the  first  layer  of  bandage,  to  strengthen  the 
dressing;  over  these  splints  another  roller  is  applied,  the  as- 
sistant all  the  time  using  as  much  paste  as  may  seem  sufficient 
to  stiffen  and  consolidate  the  dressing.  Even  the  third  roller 
may  be  employed  in  this  way  to  give  additional  strength  to 
the  dressing. 

Extension  and  counter-extension  should  be  kept  up  by  some 
of  the  means  already  indicated,  for  thirty  or  forty  hours,  when 
the  dressing  becomes  hard  and  immovable.  If  in  the  course 
of  a  few  days,  it  be  found  that  a  subsidence  of  swelling  has 
left  the  dressing  loose,  the  piece  of  tape  laid  on  the  limb  at 
first,  may  be  used  to  lift  the  hardened  case  from  the  skin,  so 
it  can  be  ripped  open  the  whole  length.  The  same  means 
may  be  used  to  free  the  constriction  in  the  event  of  swelling. 
Suetin  devised  scissors,  one  blade  having  a  probe  point,  to 
slit  up  the  starch-bandage,  and  to  cut  a  hole  in  it  to  correspond 
to  the  sore  in.  a  compound  fracture.  A  grooved  director  and 
a  bistoury  will  answer  the  purpose  of  the  scissors. 

If  the  limb  shrinks  away  to  a  considerable  extent,  the  old 
apparatus  should  be  .removed,  and  a  new  one  put  on.  An  im- 
movable dressing  is  to  extend  to  the  knee  in  case  of  fracture  of 
the  leg ;  and  to  begin  above  the  knee  and  extend  to  the  body, 
in  case  of  fracture  of  the  femur — the  knee-joint  being  left  free 
in  both  instances.  The  ankle-joint  maybe  covered,  the  dress- 
ing beginning  at  the  toes.  Lint  should  be  carefully  packed 
between  the  ankle  and  the  tendo-Achillis,  on  each  side,  that 
the  dressing  may  not  bear  too  heavily  on  the  prominences  of 
the  joint. 

GYPSUM  BANDAGE. — A  plaster  of  Paris  bandage  has  the  same 
general  features  as  the  starcn-apparatus.  A  coarse  roller  of 
muslin  is  thoroughly  dusted  with  the  powdered  o-\ -j.su m,  and 


SPLINTS.  57 

then  applied  to  the  limb.  While  the  bandage  is  being  put  on, 
it  should  be  moistened  and  freely  dusted  with  the  dry  powder 
in  order  to  strengthen  or  stiffen  the  application.  It  is  well  to 
wrap  the  limb  in  flannel  or  soft  lint  before  applying  the  gyp- 
sum bandage.  This  precaution  may  save  troublesome  irrita- 
tion. Three  rollers,  well  powdered  while  being  applied,  gen- 
erally make  a  stiff,  immovable  apparatus. 

The  advantage  of  gypsum  over  starch  is  that  it  dries  or 
"sets"  immediately.  On  the  contrary,  it  is  heavier  and  not 
so  easily  cut  away  in  the  event  of  its  being  too  tight  or  too 
loose.  When  plaster  of  Paris  is  used,  extension  should  be 
kept  up  by  assistants  for  a  few  minutes,  or  until  the  stiffening 
ingredient  has  become  solid. 

O 

The  immovable  apparatus  is  frequently  employed  in  hospi- 
tals and  public  institutions,  but  it  has  not  been  extensively 
used  in  private  practice.  There  seems  to  be  no  good  reason 
why  it  is  not  more  commonly  adopted,  as  every  house  contains 
starch,  and  the  other  means  needed  to  complete  the  dressing. 


SPLINTS. 


Splints  are  made  of  various  substances,  according  to  the 
caprice  of  the  surgeon,  or  the  nature  of  the  materials  at  hand. 
Wooden  splints  are  by  far  the  most  commonly  used  in  coun- 
try practice ;  and,  in  the  majority  of  instances,  they  are  the 
best. 

From  time  to  time  splints  of  various  materials  have  been 
introduced,  so  that  a  surgeon  in  a  large  city  can  make  his 
choice  among  a  number  of  appliances,  and  select  that  which 
he  may  fancy,  or  is  best  suited  to  his  purpose. 

The  country  practitioner  derives  little  instruction  and  con- 
solation, in  case  of  emergency,  from  illustrations  and  teach- 
ings which  deal  only  in  "  patent  splints  "  and  complicated  con- 
trivances that  can  not  at  the  time  be  obtained.  With  a  few 
practical  suggestions  he  can,  if  moderately  ingenious,  make 
from  thin  boards  all  the  splints  he  may  need,  or,  at  least,  con- 
struct a  temporary  appliance  which  will  do  till  the  village  car- 


FIIAOTKKS. 


Fie.  7. 


penter  can  furnish  him  with  a  inoiv  suitable  apparatus.  A 
shingle,  a  piece  of  lath,  a  cigar  box,  sole  leather,  binders' 
board,  pieces  of  tin,  and  other  materials  adapted 
to  the  purpose,  can  be  pressed  into  service.  A 
surgeon  of  expedients  is  rarely  baffled  through 
want  of  appliances.  Strips  of  bark,  or  even  a 
trough  of  bark  taken  from  a  sapling,  can  often 
be  used  with  great  satisfaction  in  dressing  a  frac- 
tured arm  or  leg.  Surgical  instrument  makers 
keep  for  sale  lined  splint- material,  which  consists 
of  thin  board  sawed  into  parallel  strips,  and  held 
in  place  by  a  piece  of  pliable  leather  glued  to  one 
side.  Splints  cut  of  any  desired  length  and 
width,  from  the  lined  material,  can  be  used  in  two  ways  :  t«> 
envelope  an  arm  or  thigh,  as  a  concave  splint,  the  leather 
acting  the  part  of  a  hinge  between  the  strips  ;  and,  with  the 
wooden  side  toward  the  limb,  to  answer  as  fiat  splints  for  the 
forearm  or  leg. 

Splints  of  gutta-percha  are  easily  moulded  to 
the  contour  of  the  body.  Cut  into  proper 
shape  and  size,  they  may  be  softened  in  hot 
water,  and  then  made  to  fit  the  part  to  receive 
them. 

FIG.  9. 


Splint-material 
consisting  of 
wooden  strips 

glued  to  leather. 


FIG.  8. 


!  gutta-percha 
splints. 


' 

\v li-n  splints. 


SPLINTS.  5l» 

What  are  ordinarily  called  "  carved  splints,"  several  of 
which  are  represented  in  the  accompanying  diagram,  arc  made 
from  thin  boards,  and  bent  into  desired  shapes,  the  wood  hav- 
ing first  been  rendered  pliable  by  the  action  of  steam.  These 
appliances  are  cat  and  moulded  into  various  lengths  and 
shapes  to  fit  the  arms  alid  legs,  and  fitted  with  hinges  to  span 
the  joints.  Applianees  of  this  kind  are  put  up  in  "  sets,"  and 
sold  about  the  country,  by  Welch,  Day,  and  other  manufac- 
turers of  such  wares. 

Although  such  curiously  fashioned  and  highly  polished 
pieces  of  surgical  mechanism,  make  a  display,  it  is  plain  that 
they  constitute  a  Procrustean  bed,  to  which  patients  of  all 
size.-;  and  shapes  must  conform. 

Wo  re t>  wire  has  been  cut,  bent,  and  soldered  into  various 
forms  for  the  support  of  fractured  limbs.  (Fig.  10.)  The  "Wire 
breeches,"  represented  in  the  accompanying  illustration,  are 
a  sample  of  the  manner  in  which  woven  wire  maybe  wrought 
to  suit  the  purposes  of  the  surgeon.  This  apparatus  is  one  of 

FIG.  10. 


"  Wire  breeches." 


the  best  that  can  be  employed  to  treat  fractures  of  the  neck  of 
the  femur.  The  screw  in  the  foot  piece  permits  of  making 
extension,  and  the  shape  of  the  upper  extremity  of  the  machine 
is  such  that  the  tuber  ischii  can  easily  rest  against  it  for  coun- 
ter-extending support.  The  length  of  the  limbs  can  be  accu- 
rately compared  while  the  patient  is  in  the  apparatus;  and  the 
wire  extends  so  far  above  the  hip-joint  that  the  constant  mo- 
tion between  the  fragments  is  prevented.  The  patient  can  sit 
up  in  the  apparatus  ;  and  by  having  its  upper  extremity  raised 
upon  a  temporary  support,  the  alvine  evacuations  can  be  re- 


60  FRACTURES. 

ceived  in  a  bed-pan.  The  apparatus  should  be  lined  with 
thick  flannel  before  the  patient  is  put  into  it. 

All  the  edges  of  the  wire-gauze  have  a  heavy  wire  soldered 
into  them,  to  give  the  machine  a  finish,  and  proper  firmness. 
The  "  wire  breeches  "  were  first  devised  for  the  treatment  of 
hip-disease. 

Concave  and  angular  wire  splints,  of  various  patterns  for  the 
shoulder  and  other  joints,  have  been  in  reputable  use.  They 
admit  free  ventilation,  and  are  not  particularly  heavy. 

ADHESIVE  STRIPS. — One  of  the  greatest  improvements  in 
the  treatment  of  fractures  of  the  leg,  where  it  is  necessary  to 
effect  and  maintain  extension  and  counter-extension,  has  been 
the  introduction  into  use  of  adhesive  strips,  to  take  the  place 
of  a  gaiter  or  other  contrivance  fastened  upon  the  ankle. 
Every  practitioner  who  has  had  occasion  to  make  fast  to  the 
foot  and  ankle  with  the  means  formerly  in  use,  fully  appre- 
ciates the  difficulties  growing  out  of  attempts  to  produce  ex- 
tension. Blisters,  irritations  and  excoriations  were  the  results 
of  the  gaiter  and  kindred  appliances.  Adhesive  strips  well 
applied,  and  carefully  retained  in  place  by  the  circular  and 
oblique  turns  of  other  strips,  keep  their  hold,  and  are  borne 
with  ease.  The  extending  part  of  the  dressing  with  adhesive 
strips,  may  be  applied  as  follows :  One  long  strip  is  cut,  and 

FIG.  11. 


Adhesive  strip*  applied. 

its  two  ends  made  to  adhere  to  the  sides  of  the  leg  and  ankle, 
leaving  a  loop  below  the  hollow  of  the  foot.  These  ends  will 
gradually  slide  down  the  limb  unless  they  be  bound  in  place 
by  other  strips,  which  are  applied  circularly  about  the  leg  and 
ankle,  covering  the  two  parts  of  the  first  piece  at  each  turn. 
Finally,  a  strip  or  two  may  be  applied  diagonally  to  the  others, 
to  hold  all  firmly  in  place. 

A  block  of  wood  may  be  placed  in  the  loop  to  prevent  pres- 
sure upon  the  ankle  when  the  extending  force  is  applied. 


SPLINTS. 


61 


The  strips  will  firmly  adhere  for  months  unless  some  alco- 
holic lotion  be  allowed  to  come  in  contact  with  them.  They 
rarely  need  removing  during  the  whole  period  of  treatment. 

A  doable  inclined  plane  apparatus  is  one  of  the  various  con- 
trivances to  keep  up  a  natural  extension  and  counter-exten- 
sion in  fractures  of  the  leg  and  thigh,  it  consists  of  two 
boards,  hinged  in  the  middle,  and  long  enough  to  reach  from 
the  tuber  ischii  to  the  heel.  There  is  a  foot-board  connected 
with  the  leg-piece;  and  this  is  sometimes  made  adjustable  so 
it  may  be  always  placed  in  contact  with  the  foot,  whatever  be 
the  length  of  the  limb.  The  double  inclined  plane  is  hinged 
at  its  upper  extremity  to  a  frame  or  board — the  bed-piece — and 
is  held  Hexed  at  any  angle  by  notches  in  the  lower  end  of  the 
bottom  board.  (Fig.  12.)  Side-boards  maybe  nailed  or  hinged 
to  the  halves  of  the  double  inclined  plane  bed  or  bottom 

FIG.  12. 


Double  inclined  plane  fracture  box. 


pieces,  to  form  a  fracture-box.  Into  this,  cushions  or  sand- 
bags can  be  laid,  and  then  the  broken  limb  may  be  placed 
upon  them,  and  secured  by  tapes  and  other  supports. 

Double  inclined  plane  apparatus,  with  various  modifications, 
has  been  in  use  for  centuries.  The  weight  of  the  body  and 
thigh  sliding  down  the  upper  plane,  produces  counter-exten- 
sion, and  the  inclination  of  the  leg  down  the  lower  plane — 
extension.  Additional  extending  force  is  applied  by  means 
of  the  adjustable  foot  piece  and  screws. 

Two  pieces  of  board,  hinged  with  leather  in  the  middle, 
having  a  cord  to  reach  from  one  board  to  the  other,  to  hold 
them  Hexed,  constitute  an  easily  constructed  double  inclined 
plane,  which  may  answer  every  purpose  of  a  more  compli- 
cated apparatus. 


62 


FKAOTUKS. 


Fracture-beds  are  intricate  and  costly  Affairs,  rarely  con- 
structed for  patients  in  private  practice.  They  are  not  exten- 
sively used  even  in  hospitals.  A  description  of  one  will  answer 
for  all.  That  of  Amesbnry  is  perhaps  as  good  as  any  ever 
constructed,  It  consists  of  a  horizonal  frame,  supporting 
three  pieces  of  wood,  or  planes,  hinged  together,  and  long 

enough,  when  connected, for  an 
adult  to  lie  stretched  out  upon. 
The  ii] »per  plane  receiving  the 
trunk,  is  raised  at  the  holster- 
end  ;  the  middle  one,  intended 
for  the  thighs,  is  made  of  tw<> 
pieces  sliding  on  one  another 
so  as  to  suit  limhs  of  different 
lengths,  and  forms  with  the 
third  piece  a  douhle  inclined 
plane;  this  last,  which  supports 
the  legs,  has  a  foot-piece,  u>ed 
to  confine  the  feet  when  it  i- 
necessary,  and  always  serving 
to  sustain  the  weight  of  the  hed 
clothes.  The  upper  of  these 
planes  is  to  be  supplied  with 
a  thick  mattress ;  the  two 
others,  with  similar  ones  only 
half  as  thick.  The  middle 
one  has  an  opening,  with  a  La- 
sin  titted  to  it  to  receive  the 
f«ucal  evacuations  ;  and  the  pel- 
vis is  fixed  by  means  of  a  belt 
passing  across  the  upper  of  the 
three  planes.  The  hinges  of 
the  apparatus  allow  the  differ- 
ent angles  to  be  changed  at 
will.  Burge's  apparatus,  (Fig.  14.)  consisting  of  a  bed,  and 
an  arrangement  to  make  extension  and  counter-extension  in 
treating  fractures  of  the  femur,  is  a  useful  piece  of  surgieal 
and  mechanical  mechanism,  but  it  is  too  complicated  and  ex- 
pensive for  ordinary  use.  The  diagram  presented  to  illustrate 
the  appliance,  shows  that  the  machine  could  not  be  constructed 
for  less  than  fifty  dollars  ;  and  is  made  of  so  many  different 


SPLINTS. 


63 


materials  that  it  would  require  a  carpenter,  blacksmith  and 
upholsterer  to  construct  the  apparatus.  Many  intricate  con- 
trivances of  varied  merit  have  been  pressed  upon  the  attention 


FIG.  14. 


Burire's  fracture-bed. 

of  the  profession  from  time  to  time,  but  none  have  come  into 
general  use.  If  a  surgeon  were  to  possess  all  the  different  ap- 
pliances devised  to  treat  fractures,  he  would  need  extensive 
store  rooms  in  connection  with  his  office,  to  give  them  shelter. 
The  simplest  and  best  method  of  exerting  extension  and 
counter-extension  in  the  treatment  of  fractures  of  thelegand 
thigh,  is  to  secure  the  limb  to  the  foot  of  the  bed  by  using  ad- 
hesive strips  upon  the  leg  and  ankle  as  an  attachment  for  a 
cord  to  make  fast  to  the  lower  end  of  the  bed.  Elevation  of 
the  foot-posts  by  means  of  blocks  piled  one  upon  another,  to 
the  height  of  eight  or  ten  inches,  secures  a  sliding  inclination 
of  the  patient's  body  towards  the  head  of  the  bed,  and  thus 
exerts  both  extension  and  counter-extension  upon  the  broken 
limb.  The  force  exerted  is  sufficient  and  easily  borne.  A 
restless  child  will  bear  this  dressing  without  complaining.  If 
splints  be  kept  snugly  applied  to  the  fractured  limb,  the  re- 
sult will  be  recovery  without  shortening  or  other  deformity. 


CHAPTER    IX. 
RE-DRESSINGS. 


After  a  fractured  limb  lias  been  dressed,  or  "  put  up,"  to 
use  a  phrase  of  the  London  hospitals,  it  becomes  a  question 
when  it  should  be  re-dressed.  According  to  some  of  the  older 
authorities  a  definite  time  should  be  allowed  to  pass  before  the 
dressing  is  meddled  with ;  and  not  a  few  timid  followers  of 
revered  authority  have  permitted  their  patients  to  suffer  need- 
less torture,  inflicted  by  swelling  and  tight  bandages,  because 
the  prescribed  time  for  re-dressing  had  not  arrived. 

"Whenever  a  fractured  limb  undergoing  treatment  is  painful, 
it  is  in  danger,  and  should  be  undressed  at  once,  that  the 
cause  of  the  distress  may  be  ascertained  and  averted.  If 
local  pain  and  general  uneasiness  arise  within  twelve  hours 
after  the  bandage  or  apparatus  is  applied,  the  limb  should  be 
re-dressed.  An  opiate  or  anodyne  to  allay  the  pain  excited  by 
the  movements  of  the  limb  during  the  manipulations  of  dress- 
ing, may  not  be  out  of  place,  but  repeated  and  heavy  doses 
of  any  narcotic  to  allay  the  distress  occasioned  by  the  constric- 
tion of  a  tight  bandage,  may  benumb  the  pain ;  yet  while  the 
wails  of  the  patient  are  thus  silenced,  the  dreaded  gangrene 
may  be  doing  its  fatal  work. 

If  the  first  dressing  is  well  applied,  and  no  swelling  comes 
on  to  convert  the  retaining  tapes  and  bandages  into  constrict- 
ing cords,  the  compresses,  splints  and  bandages  may  be  left  in 
place  for  several  days.  I  have  frequently  left  the  dressings  a 
week  or  ten  days  without  interference.  Frequent  renewals, 
without  substantial  reasons  for  them,  are  worse  than  useless. 
They  hinder  the  healing  process,  give  the  fragments  an  oppor- 
tunity to  play  upon  one  another,  and  to  overlap  in  cases  where 
that  condition  is  possible. 

(64) 


IvE-DRESSINGS.  65 

As  soon  as  the  swelling  has  subsided,  and  the  shrinking  of 
the  limb  permits  the  bandages  to  become  loose,  a  renewal  of 
the  dressing  should  take  place.  It  is  probably  best,  in  favor- 
able cases,  to  re-dress  once  a  week  while  the  retentive  treat- 
ment lasts.  The  limb  may  be  looked  at  ofteiier.  A  case  that 
is  convenient  to*  watch  may  be  seen  every  other  day ;  if  it 
be  at  a  distance,  and  circumstances  do  not  favor  any  more 
attention  than  is  absolutely  necessary,  a  revisit  and  redressing 
once  in  ten  days  may  do  just  as  well  as  daily  inspections. 
There  is  generally  intelligence  enough  among  the  patient's 
friends  to  be  entrusted  with  the  execution  of  certain  instruc- 
tions pertaining  to  the  case.  If  yellow  blisters,  or  a  livid 
color  of  the  skin,  show  themselves  between  the  folds  of  the 
bandage  or  anywhere  beneath  the  dressings,  the  surgeon  can 
be  informed  of  the  untoward  condition.  A  too  tight  dressing- 
can  be  loosened  by  cutting  a  few  of  the  turns  of  the  bandage 
partly  or  wholly  in  two;  and,  in  the  event  of  loosening,  a  few 
additional  tapes  can  be  tied  around  the  dressing. 

In  fractures  of  the  thigh  or  leg,  the  surgeon  should,  every 
time  he  visits  the  patient,  compare  the  two  limbs  in  regard  to 
length,  direction  of  feet,  and  general  aspect.  This  can  be  done 
before  the  dressing  is  removed.  The  patient,  while  his  limbs 
are  inspected,  should  be  made  to  lie  on  his  back,  straight  in 
bed.  A  slight  twist  of  the  pelvis  makes  a  great  difference  in 
the  apparent  length  of  the  legs.  With  the  trunk  and  limbs 
straight,  accurate  measurements  with  a  tape  or  inelastic  cord 
should  be  made  from  the  symphysis  pubis  to  the  inner  mal- 
leolus  of  both  ankles.  The  placing  of  the  two  heels  together 
and  observing  whether  one  is  below  the  other,  is  a  good  test 
of  the  relative  length  of  the  limbs.  If  there  be  evidence  of 
shortening,  the  dressing  should  be  taken  off,  and  the  defect  or 
displacement  remedied.  Re-dressings  for  such  a  purpose  are 
always  proper,  even  at  the  risk  of  disturbing  the  healing  pro- 
cess. There  is  always  an  urgent  necessity,  on  the  part  of  both 
surgeon  and  patient,  to  avoid  deformity  if  possible. 


MOVEMENTS  ALLOWED  A  PATIENT. 


After  a  fracture  of  the  arm  has  been  dressed,  and  the  limb 
is  suspended  in  a  sling  hanging  from  the  neck,  the  patient  can 
take  moderate  exercise  upon  his  feet.  Motion  at  the  point  of 
fracture,  for  obvious  reasons,  is  to  bo  guarded  against.  In 
fact,  the  patient,  to  avoid  pain,  is  very  likely  to  rairy  a  broken 
arm  with  much  care.  If  the  dressing  become  loose,  the  morion 
between  the  fragments  tends  to  establish  false-joint. 

After  fractures  of  the  femur,  and  of  both  bones  of  the  leg, 
the  patient  must  keep  quiet  in  bed  during  treatment,  unless 
an  immovable  apparatus  be  applied.  In  a  fracture  of  one  of 
the  bones  of  the  leg,  the  condition  is'  different.  The  unbroken 
bone  prevents  shortening,  and  acts  as  a  stay  or  support  to  the 
one  fractured.  A  patient  with  a  broken  tibia  or  fibula  well 
dressed,  can  go  about  on  crutches. 

In  fractures  of  the  femur,  it  is  dangerous  for  the  patient  to 
go  on  crutches,  even  if  the  immovable  apparatus  be  employed. 
If  the  fracture  be  of  the  cervix,  or  through  the  upper  third  of 
the  bone,  it  is  difficult  for  the  bed-pan  to  be  used  without  im- 
parting more  or  less  motion  to  the  fragments.  A  cord  sus- 
pended from  the  ceiling,  which  can  be  grasped,  enables  the 
patient  to  raise  himself  with  less  motion  than  he  can  be  raised 
by  the  efforts  of  assistants.  If  the  patient  is  too  feeble  to 
raise  himself,  an  .assistant  can  do  it  by  placing  a  hand  in  each 
loin,  and  lifting  upwards  and  drawing  backwards  at  the  same 
time.  This  prevents  the  body  from  sliding  down  in  bed,  or 
the  pelvis  from  descending  upon  the  broken  thigh.  The  body 
may  also  be  kept  from  sliding  downwards,  by  using  a  perineal 
band,  which  is  to  be  tied  to  the  head  of  the  bed.  A  box  or 
block  so  placed  that  the  sound  foot  may  press  against  it,  in 
efforts  to  raise  the  pelvis,  may  be  of  considerable  service. 

(66} 


CHAPTER    XI. 


MANAGEMENT  OF  COMPOUND  FRACTURES. 


The  directions  given  by  Ambrose  Pare,  himself  an  eminent 
surgeon,  to  his  surgical  attendant,  when  he  received  a  com- 
pound fracture  of  the  leg,  are  quite  explicit.  "  If  the  wound 
be  too  small,  enlarge  it  with  a  razor,  that  YOU  may  the  more 
easily  replace  the  bones  in  their  natural  position  ;  and  carefully 
explore  the  wound  with  the  fingers,  in  order  to  remove  such 

fragments  and  bits  of  bone  as 
maybe  completely  detached 
and  press  out  the  blood 
which  has  become  effused 
about  the  wound."  This 
suggestion,  to  clear  the  cav- 
ity of  the  wound  from  blood 
and  splinters,  is  generally  to 
be  followed.  Small  fragments 
isolated  from  the  periosteum, 
are  likely  to  create  as  much 
trouble  as  other  foreign  bod- 
ies in  the  flesh. 

The  wound  once  cleared 
of  coagula,  splinters,  dirt, 
and  other  foreign  substa; 
and  the  fragments  adjusted, 
the  treatment  is  much  the 
same  as  in  simple  fractures. 

Compound  fracture.  The.  Dressing  should  be   so 

applied  as  not  to  permanent- 
ly cover  and  choke  the  wound,  for  it  must  have  an  opportu- 
nity for  the  free  escape  of  pus  and  other  fluids.  When  the 
immovable  apparatus  is  employed,  the  wound,  while  the 

(67)    ' 


68  FRACTURES. 

dressing  is  being  put  on,  is  covered  in  ;  but,  after  the  dressing 
has  become  consolidated,  a  hole  or  door  is  cut  so  as  to  expose 
the  wound. 

The  edges  of  the  wound  are  not  to  be  drawn  together  with 
sutures,  but  a  piece  of  tin-foil,  or  a  lead  plaster,  may  be  em- 
ployed to  shield  the  lacerated  parts.  As  previously  stated, 
the  many-tailed  bandage  is  well  suited  for  the  treatment  of 
such  injuries,  inasmuch  as  the  wound  can  be  often  exposed 
without  disturbing  the  limb.  Care  must  be  exercised  that 
flies  do  not  deposit  their  ova  in  the  saturated  folds  of  cloth 
about  the  wound. 

The  immovable  apparatus  is  not  generally  suitable  for  com- 
pound fractures.  Unpleasant  complications  have  too  often 
arisen  when  it  has  been  used.  Malgaigne  says  of  it :  "  Un- 
happily we  have  too  much  reason  to  fear  pus  will  burrow  be- 
tween the  integuments  and  the  muscles,  and  between  the 
muscles  and  the  bones,  endangering  the  limb  and  even  the 
life  of  the  patient.  I  once  had  to  treat  an  old  soldier,  a  stout, 
sanguine  man,  who  fell  from  a  ladder,  and  sustained  a  com- 
pound fracture  of  the  tibia  at  its  lower  part.  The  immovable 
apparatus  was  employed  ;  on  the  eighteenth  day  it  had  to  be 
removed  on  account  of  the  insupportable  fetor.  Four  days 
later,  pus  flowed  abundantly  from  the  heel.  On  the  twenty- 
ninth  day,  the  increased  discharge  and  the  excessive  fetor 
made  a  fresh  removal  necessary;  the  whole  leg  was  pasty  and 
flaccid  ;  a  probe,  introduced  by  the  wound,  passed  up  several 
inches  between  the  two  bones ;  the  tibia  was  denuded  at  its 
external  face;  sinuses  were  formed  in  the  limb  above  and 
below.  Several  surgeons  regarded  amputation  as  unavoidable. 
This,  however,  was  postponed,  and  by  great  care,  after  three 
incisions  had  been  made,  and  a  long  train  of  severe  symptoms 
had  been  overcome,  a  satisfactory  cure  was  effected  by  the 
end  of  six  months." 

The  application  of  carbolic  acid  in  a  dilute  form,  to  the 
wound  of  a  compound  fracture,  is  valuable  to  remove  the 
fetor;  to  prevent  a  profuse  suppurative  condition  ;  and  to 
favor  the  formation  of  firm  and  healthy  granulations. 


TOPICAL  TREATMENT.  69 

TOPICAL  AND    CONSTITUTIONAL    TREATMENT. 

It  was  once  customary  to  apply  cerates,  poultices,  and  fo- 
mentations to  fractured  limbs.  At  a  later  period  in  the 
history  of  surgery,  it  was  a  common  practice  to  soak  the 
dressings  in  laudanum,  braudy,  lead-water,  camphorated 
liquids,  and  various  other  lotions.  At  the  present  day,  dilute 
tinctures  of  aconite,  arnica,  and  wormwood,  are  thought  to 
be  valuable  applications  ;  rum  and  whisky  have  always  en- 
joyed a  popular  reputation  for  allaying  inflammation  in  almost 
every  kind  of  injury.  Some  practitioners  order  the  frequent 
application  of  water  to  fracture  dressings,  with  the  object  of 
cooling  the  inflamed  tissues  beneath. 

The  reasons  adduced  for  employing  cooling,  stimulating, 
and  anodyne  lotions  are  not  without  plausibility,  ;yet,  in  prac- 
tice, it  is  found  that  more  harm  than  good  follows  any  kind 
of  topical  medication.  A  common  muslin  bandage  creases 
upon  being  wetted,  often  rendering  the  dressing  harmful ; 
then,  if  allowed  to  dry,  as  is  frequently  the  case,  it  will  be  too 
loose.  Blisters  are  more  likely  to  occur  under  wet  dressings; 
eruptions  and discolorations,  with  itching  and  other  unpleasant 
sensations,  are  among  the  troublesome  effects  produced  by 
lotions.  I  invariably  lind  that  fractured  legs  do  the  best  when 
treated  with  dry  dressings.  Much  is  said  by  those  whose  ex- 
perience ought  to  render  them  competent  authority,  about 
applying  evaporating  lotions  to  fracture  injuries  of  the  elbow, 
knee,  and  other  large  joints,  yet  the  instances  are  few  in  which 
I'  could  approve  of  such  treatment. 

The  extensive  ecchymosis  that  occasionally  attends  upon  a 
fracture  of  the  leg,  excites  dire  apprehension  on  the  part  of  the 
patient,  yet  the  extravasation  of  blood  and  discoloration  rarely 
result  in  any  harm.  Neither  leeches  nor  stimulating  lotions 
will  prevent  the  spread  of  the  discoloration,  or  remove  the 
effused  blood  and  serum. 

If,  upon  the  renewal  of  a  dressing,  it  be  found  that  large 
blisters  exist,  the  bags  of  serum  maybe  punctured,  care  being 
exercised  that  the  subsequent  dressing  does  not  press  upon 
the  parts  lest  suppuration  and  sloughing  follow.  The  surgeon 
should  frequently  re-dress  a  limb  in  a  blistered  condition,  or 
watch  it  carefully  until  parts  thus  effected  are  sound. 


70  FRACTURES. 


is  occasionally  a  disagreeable  complication 

which  needs  subduing.  The  application  of  chloroform  to  the 
limb  may  allay  the  difficulty  ;  the  internal  use  of  an  opiate 
has  been  attended  with  relief,  though  some  patients  of  great 
nervous  excitability  grow  worse  under  its  administration. 
Chlorodyne  has  a  far  more  desirable  effect  upon  spasmodic 
conditions. 

Di-fi  reusing  pain  attendant  upon  the  reception  of  a  fracture, 
and  the  disturbance  caused  by  the  reducing  process,  ought  to  be 
assuaged  by  anodynes  in  doses  gauged  by  the  severity  and 
continuance  of  the  distress. 

Ftln-ile  ,«i/i>ij>tom$  may  be  allayed  by  the  use  of  aconite,  or 
kindred  agents.  The  evacuation  of  the  bowels  by  the  inilu- 
ence  of  an  enema,  or  a  mild  purgative,  frequently  arrest.- 
feverish  paroxysms.  A  hot  skin  may  be  cooled  by  the  fre- 
quent use  of  the  wet  sponge.  In  case  of  "  chills  "  and  In- 
from  exhaustive  suppuration,  iron,  quinine,  and  the  mineral 
acids  may  be  employed  to  advantage. 

The  diet  should  be  light  for  the  first  few  days  after  the  in- 
jury, but  in  the  course  of  a  week  or  ten  days,  it  may  be  sub- 
stantial and  nourishing. 

Excoriations  on  the  nates  arising  from  unsuitable  beds,  and 
a  prolonged  recumbent  position,  may  generally  be  prevented 
by  the  use  of  a  soft  piece  of  buckskin  to  parts  threatened 
with  such  a  disagreeable  complication.  Air  and  water-cushions 
are  useful  in  protecting  parts  irritable  and  excoriated  from 
prolonged  pressure  of  the  bed. 

CONVALESCENCE. 

There  is  generally  too  little  attention  given  to  patients  after 
the  fracture  apparatus  is  removed.  The  limb,  though  the 
broken  bone  has  united,  remains  stiff,  swollen,  weak  and 
tender.  Compression  and  inaction  have  established  a  condi- 
tion of  atrophy;  and  the  neighboring  joints  have  lost  their 
suppleness.  A  patient  is  very  sensitive  to  this  enfeebled  suite 
of  the  limb,  and  needs  encouragement  to  make  him  exei 
properly,  and  to  employ  those  means  which  tend  to  re-estab- 
lish the  functions  of  the  part.  Extreme  timidity  prevents 
patients  from  giving  their  eonvale-cinir  limbs  a  desirable 


CONVALESCENCE.  71 

amount  of  action.  There  is  an  instinctive  dread  tliat  the  limb 
may  be  re-broken,  or  that  it  will  not  sustain  the  weight  of  the 
body. 

It  is  a  discreet  precaution  to  keep  patients  who  have  sus- 
tained a  fracture  of  the  thigh,  or  of  both  bones  of  the  leg,  in 
bed  for  a  week  or  two  after  the  consolidation  is  known  to 
have  been  established.  As  has  been  previously  stated,  there 
is  yet  danger  of  a  gradual  yielding  of  the  newly-formed  callus  > 
yet  during  this  confinement  to  the  bed,  the  limb  may  be  moved 
at  the  joints,  and  rubbed  with  the  hand  or  coarse  towels.  At 
length  the  patient  may  venture  upon  crutches,  and  then  to 
take  gentle  exercise  with  the  support  of  a  cane ;  and,  finally, 
he  will  walk  without  any  assistance,  though  with  a  limp  in 
the  gait  even  when  there  is  no  shortening  or  other  deformity. 

Sometimes  a  patient  is  so  fearful  of  a  fall  or  a  second  acci- 
dent, that  he  has  to  be  coaxed  and  urged  into  sufficient  exer- 
cise to  invigorate  the  limb.  Liniments  and  douches  are  of 
questionable  utility  so  far  as  medication  is  concerned,  but 
their  indirect  effects  may  prove  exceedingly  advantageous. 
The  patient  is  recreated  while  applying  a  liniment;  and  the 
circulation  of  the  limb  is  improved  by  the  friction  employed 
in  the  application.  There  is  a  popular  notion  that  certain 
penetrating  or  oleaginous  liniments  will  impart  suppleness  to 
stiffened  joints  and  rigid  tissues;  this  prejudice  maybe  turned 
to  the  advantage  of  the  sufferer,  for  he  will  industriously 
employ  any  means  that  have  ascribed  to  them  the  desired 
qualities. 

Patients  are  to  be  impressed  with  the  importance  of  em- 
ploying considerable  force  in  the  flexion  and  extension  of  par- 
tially anchylosed  joints;  and  of  keeping  up  this  action  for 
weeks  and  even  months  in  obstinate  cases.  Persevering  efforts 
of  this  kind  have  accomplished  wonderfully  beneficial  results. 

Flannel  bandages  should  be  kept  applied  for  weeks  and 
months  to  legs  inclined  to  swell,  especially  if  the  veins  be 
varicose.  At  length  the  bandages  may  be  laid  aside,  and 
elastic  stockings  worn  continuously  to  keep  the  limbs  in  good 
condition.  Elderly  persons  make  exceedingly  slo\v  recoveries  ; 
and  if  of  irritable  temperaments,  are  querulous  and  de- 
spondent. 


CHAPTER    XII. 
DIASTASIS,  OR  SEPARATION  OF  THE  EPIPHYSIS. 


Strictly  speaking,  there  can  be  no  fracture  without  breaking 
of  osseous  material,  yet  the  forcible  separation  of  the  epiphy- 
sis  from  the  shaft  of  the  bone,  through  the  cartilaginous  con- 
nection, in  young  subjects,  is  a  lesion  analogous  to  fracture. 
It  is  an  accident  that  can  not  always  be  distinguished  from 
fracture  ;  and  the  treatment  of  the  lesion  should  be  the  same 
as  that  directed  for  a  broken  bone.  In  the  diagnosis  of  the 
case,  clear  and  distinct  crepitus  will  be  wanting,  but  all  the 
other  signs  of  fracture  may  be  present. 

All  the  long  bones,  from  birth  to  fifteen  years  of  age,  are 
subject  to  this  peculiar  injury.  Both  extremities  of  the 
humerus,  radius,  femur,  and  tibia,  have  been  separated  from 
the  shaft,  through  the  cartilages  interposed  in  growing  bones, 
between  these  distinct  ossific  parts.  The  separation  may  take 
place  during  the  careless  delivery  of  a  child.  The  obstetrician, 
unless  he  bears  in  mind  the  dangers  of  diastasis,  may,  in  at- 
tempts to  bring  down  an  arm  or  leg,  sever  the  cartilaginous 
connections  of  the  hnmerus  or  femur.  If  such  an  accident 
should  occur,  it  would  be  known  by  the  flaccid,  mobile  condi- 
tion of  the  broken  limb.  Swelling  and  discoloration  would 
soon  exhibit  themselves  ;  and,  in  handling  the  child,  the  in- 
stability of  the  member  would  be  observable.  The  limb  would 
fall  powerless  into  unnatural  attitudes.  Once  discovered,  the 
injury  should  be  treated  like  an  ordinarj7  fracture. 

I  was  once  called  to  attend  a  lad  of  five  or  six  years  of  age, 
who  had  separated  the  lower  epiphysis  (Fig.  16)  of  the 
humerus,  by  a  fall  upon  the  curbstone.  The  physician  first 
summoned  to  take  charge  of  the  case,  bandaged  the  arm  so 
tightly  that  the  soft  parts,  on  the  anterior  aspe  -t  of  the  arm, 
sloughed.  This  was  the  state  of  the  case  \vlieu  I  \vas  ;i<k<-d 

(72) 


DlASTASIS. 


73 


to  take  charge  of  it.  The  shaft  of  the  humerus  protruded 
tlirough  the  opening  made  by  the  slough,  converting  the 
lesion  into  something  like  a  compound  fracture.  The  pro- 
truding bone  was  denuded  of  periosteum,  and  pus  was  dis- 
charged through  two  sinuses  above  the  main  opening.  The 


FIG.  16. 


Separation  of  the  lower  epiphysis  of  the  humerus. 

fortunate  discovery  of  granulations  upon  the  end  of  the  pro- 
truding bone,  suggested  the  idea  of  extending  the  limb  until 
the  projecting  bone  would  sink  into  its  natural  place  and 
position.  Accordingly,  the  hand  was  suspended  to  the  bed- 
frame  above,  so  that  the  weight  of  the  body,  by  extension, 
kept  the  bone  where  it  ought  to  be,  in  the  bottom  of  the 
wound.  The  period  of  recovery  was  prolonged,  and  attended 
with  profuse  suppuration,  yet  in  the  end  the  result  was  quite 
satisfactory,  considering  the  condition  of  the  limb. 

Diastasis  often  takes  place  at  the  point  of  the  elbow, — there 
is  u  partial  separation  of  the  epitrochlea.  The  injury  is  at- 
tendeil  wMh  great  pain  ;  and  occurring  in  children  whose 
joints  arc  loose  and  who  sob  a  great  deal,  the  surgeon  is  puz- 
zled to  know  what  kind  of  an  accident  has  happened.  Xo 
crepitation  eau  be  elicited,  and  little  displacement  is  apparent. 

It  is  safe  to  manage  these  obscure  and  doubtful  cases  by 
placing  an  angular  piece  of  binder's  board  on  the  posterior 
aspect  of  the  limb,  the  ends  extending'  three  or  four  inches 
above  and  below  the  joint,  and  wrap  splint  and  arm  with  a 
bandage.  If  a  piece  of  binder's  board  eight  inches  long  and 
three  or  four  inches  wide  be  cut  into  on  each  side,  the  inci- 
sions extending  obliquely  towards  the  centre  of  the  material, 
the  piece  can  easily  be  bent  into  a  nest  that'  quite  accurately 
fits  over  the  joint  of  the  elbow. 


CHAPTER   XIII. 
FRACTURES  OF  THE  CRANIUM. 


In  the  division  of  surgical  subjects,  fractures  of  the  cranium, 
from  the  nature  of  the  injuries  and  the  peculiarity  of  their 
treatment,  are  always  placed  among  \vounds  of  the  head. 
The  gravity  of  such  lesions  depends  essentially  upon  injuries 
and  disturbances  of  the  brain,  therefore  a  consideration  of  tin-- 
fracture alone  would  not  reach  the  most  important  part  of  the 
subject.  The  treatment  of  fractures  of  the  cranium  is  not 
based  upon  the  ordinary  rules  pertaining  to  broken  bones,  but 
upon  the  brain-symptoms.  Unaccompanied  with  cerebral 
complications,  such  fractures  though  almost  always  compound, 
are  not  to  be  interfered  with.  It  is  an  established  rule  that 
simple  fractures  of  the  skull,  even  with  depression,  but  with- 
out encephalic  symptoms,  are  to  be  let  alone.  In  the  severer 
cases,  the  surgical  interference  chiefly  consists  in  trephining, 
an  operation  performed  in  order  to  elevate  or  remove  frag- 
ments of  bone,  and  designed  to  relieve  the  brain-symptoms. 
Fractures  of  the  cranium,  then,  will  not  receive  attention  in 
this  connection.  The  bones  of  the  face,  though  classed  as 
belonging  to  the  skull,  may  be  broken  without  necessarily 
disturbing  the  brain  ;  and  require  the  same  general  treatment 
as  fractures  in  other  parts  of  the  body. 

FRACTURE  OF  THE  ZYGOMATIC  ARCH. 

A  fracture  of  the  zygomatic  process  of  the  temporal  bone 
is  an  exceedingly  rare  accident.  A  direct  blow,  as  a  fall  upon 
the  side  of  the  head,  is  the  kind  of  violence  most  liable  to 
break  this  bony  arch.  Although  very  prominent  and  slender, 
the  process  is  protected  by  coverings  of  integument,  fat.  fascia. 
muscle,  and  other  soft  structures. 

(74) 


FRACTURES  or  THE  XASAL  BOXES.  7-0 

A  simple  fracture  of  the  zygoma  is  an  unimportant  injury, 
but  a  force  that  breaks  the  process  of  bone,  is  generally  suffi- 
cient to  do  other  mischief.  Concussion  of  the  brain  is  the 
frequent  attendant  of  such  a  lesion.  A  depression  of  the  arch 
interferes  with  the  temporal  muscle.  The  swelling  that  follows 
the  injury  also  impedes  the  functions  of  the  parts  implicated. 

TREATMENT. — In  cases  where  the  temporal  muscle  plays 
easily,  and  the  depression  of  the  arch  is  not  distinct,  no  treat- 
ment is  necessary,  unless  it  be  that  employed  in  ordinary  con- 
tusions. Duverney  direc-ts,  in  the  event  of  depression  of  the 
arch,  that  the  surgeon  put  his  finger  in  the  back  part  of  the 
patient's  mouth,  against  the  inner  surface  of  the  cheek,  and 
press  the  displaced  fragments  back  into  their  natural  line. 
An  attempt  to  bring  force  against  the  inner  surface  of  the 
/.yu'omatic  arch,  b}'  a  finger  in  one's  own  mouth,  shows  that 
such  a  method  of  reduction  is  impracticable. 

Ferrier  brought  the  pieces  to  their  natural  level,  by  cutting- 
down  upon  the  fracture,  and  elevating  them  with  a  spatula. 

In  the  only  case  I  ever  saw,  the  patient  had  been  struck 
with  a  heavy  chisel.  A  plain  depression  in  the  arch  could  bo 
felt ;  and  the  sufferer  could  open  and  shut  the  mouth  with 
difficulty.  There  was  marked  ecchymosis  in  the  region  hurt. 
The  skin  was  broken,  but  there  was  no  wound  in  the  soft  parts 
reaching  to  the  bone.  I -pushed  the  point  of  a  strong  tenaculum 
beneath  the  depressed  bone,  and  with  a  lever-like  motion, 
forced  the  displaced  fragment  into  line.  There  was  a  perfect 
recovery  in  six  or  eight  weeks,  no  perceptible  deformity  fol- 
lowing. The  point  of  an  instrument,  like  a  carpenter's  scratch- 
awl,  might  be  employed  as  a  lever  to  overcome  the  displace- 
ment. 

FRACTURE   OF   THE   OSSA  XASL 

A  not  unfrequent  injury  is  fracture  of  the  nasal  bones.  It 
may  be  produced  by  the  kick  of  a  horse  or  mule,  and  by  the 
forces  of  moving  machinery.  A  circular  saw  might  throw  a 
block  of  wrood  with  sufficient  velocity  to  crush  the  bones  of 
the  nose.  The  handle  of  a  windlass,  while  heavy  weights  are 
being  raised,  may  slip  out  of  the  hand  of  a  laborer,  and  so 
quickly  take  the  reverse  direction  as  to  strike  the  workman 
across  the  bridge  of  the  nose. 


76  FRACTURES. 

Violence  producing  fracture  of  the  nasal  bones,  rarely  stops 
with  that  injury.  The  ascending  processes  of  the  superior 
maxillary  are  adjacent  to  the  ossa  nasi,  the  central  lamella, 
and  cells  of  the  ethmoid  are  directly  beneatji,  and  the  voim-r 
and  turbinated  bones  not  far  away.  The  nasal  duct  may  be 
lacerated,  and  the  Schneiderian  membrane  is  sure  to  be  torn. 
The  symptoms  of  fracture  which  amount  to  reliability,  are 
displacement.  This  may  elude  observation,  on  account  of  the 
great  swelling  which  immediately  follows  the  accident,  unless 
the  surgeon  presses  his*  ringers  deep  into  the  tumefied  tissues, 
and  thus  discovers  that  the  nasal  bones,  wholly  or  in  part,  arc 
depressed  below  their  natural  position.  The  profuse  hemor- 
rhage from  the  anterior  nares,  and  other  conditions  generally 
attendant  upon  fracture  of  the  nose,  assist  in  the  diagnosis, 
yet,  without  other  evidence  of  fracture,  the  case  would  be- 
likely  to  pass  unrecognized.  Ecchymosis  and  swelling,  which 
extend  to  the  eyelids,  are  the  usual  concomitants  of  contusions 
in  the  vicinity  of  the  nose,  and  do  not  indicate  the  existem-e 
of  a  fracture.  Even  the  introduction  of  a  probe  into  the  nos- 
trils determines  nothing  positively,  unless  it  forces  one  frag- 
ment against  another,  producing  crepitus.  The  nasal  bunt's 
may  be  broken  and  displaced,  yet  the  fragments  may  be  so 
wedged  against  one  another,  and  between  other  bones,  that 
no  crepitus  can  be  elicited.  When  the  fracture  is  much  com- 
minuted, motion  between  the  fragments  can  easily  be  given 
by  holding  the  nose  between  the  finger  and  thumb,  and  push- 
ing it  laterally,  or  from  side  to  side.  If  a  grooved  director  be 
carried  up  the  nostril  beneath  the  fragments,  and  the  ringer  be 
held  upon  the  outside  injury,  alternate  motion  given  by  either 
instrument  may  disclose  crepitus,  and  a  pretty  clear  idea  o! 
the  state  of  the  parts.  In  the  event  of  a  wound  exposing  the 
bones,  it  would  not  be  difficult  to  discover  whether  a  fracture 
had  been  received  or  not. 

TREATMENT. — Diagnosis  having  been  established,  the  sur- 
geon's next  duty  is  plain,  though  not  easily  accomplished  in 
every  instance.  A  profuse  and  persistent  hemorrhage  is  to  bo 
arrested  before  dangerous  syncope  comes  on.  The  displaced 
fragments  of  bone  ought  to  be  reduced,  it'  possible,  for  no  de- 
formity is  so  noticeable  as  a  flattened  or  distorted  nose.  A 
female  catheter,  grooved  director,  or  other  similar  instrument, 
may  prove  a  sufficiently  firm  lever  when  inserted  in  the 


FRACTURES  OF  THE  XASAL  BONES.  77 

to  force  the  fragments  back  into  place,  but  in  some  instances, 
a  pen-handle,  or  piece  of  hickory  \vood  whittled  into  the  form 
of  a  pencil,  may  be  required  as  a  lever  to  elevate  the  bones 
from  their  depre»ed  position.  This  elevator,  first  carried  up 
one  nostril,  and  then  the  other,  to  a  point  beneath  the  depres- 
sion, then,  being  poised  on  tne  forefinger  which  rests  on  the 
upper  lip,  is  made,  by  a  lever  motion,  to  pry  the  fragments 
into  their  normal  position.  Once  replaced,  the  bones  will  stay 
where  thev  belong.  Pledgets  of  lint  st lifted  into  the  nasal 

•  o  o 

cavities  to  prevent  the  bones  from  fall  ing  out  of  place,  cannot 
accomplish  any  good  purpose.  Petit  remarks  :  "These  plugs 
are  only  of  use  to  contain  the  medicaments;  and  those  who 
have  thought  of  putting  pings  of  lint  with  the  idea  of  sup-' 
porting  tin;  bones,  for  fear  they  should  be  displaced,  have 
never  made  the  reduction  of  a  single  fracture  of  the  nose  : 
experience  \vonkl  have  taught  them  that  it  requires  more  force 
to  depress  these  bones  that  have  just  been  replaced,  than  was 
-<ary  to  raise  them  up  with  the  elevator." 

If  the  bones  be  much  comminuted,  the  parts  may  be  quite 
moveable  and  require  some  lateral  support.  This  may  be 
brought  to  bear  by  the  use  of  small  compresses,  one  placed  on 
either  side  of  the  nose,  and  held  there  with  strips  of  adhesive 
plaster. 

In  many  accidents,  the  fracture  of  the  nasal  bones  is  the 
least  important  part  of  the  injury.  There  may  be  emphysema, 
the  air  from  the  nostrils  finding  its  way  from  cell  to  cell,  or 
tissue  to  tissue,  till  the  parts  about  the  eyes  and  face  are  dan- 
gerously infiltrated ;  lachrymal  fistula  is  another  unpleasant 
complication  ;  and  thecrista  galli  of  the  ethmoid  bone  maybe 
forced  upwards  or  to  one  side,  and  do  serious  harm  to  the 
brain,  or  structures  within  the  skull. 

A  lateral  deviation  of  the  nasal  appendage  is  not  so  objec- 
tionable a  deformity  as  flattening  or  sinking  do\vn  of  the 
bridge,  yet  much  care  should  be  exercised  from  day  to  day, 
during  the  healing  process,  to  prevent  any  lateral  tendency. 
A-  -oon  as  the  swelling  about  the  nose  and  eyelids  subsides, 
any  depression  or  lateral  deviation  can  be  readily  detected ; 
and  if  the  injury  be  not  more  than  two  or  three  weeks  old,  the 
defect  may  be  remedied.  After  consolidation  of  the  frag- 
ments, no  correcting  operation  should  be  adopted,  so  far  as 
the  position  of  the  bones  is  concerned. 


78  FllACTURES. 

FRACTURE    OF   THE   MALAR   BOXES. 

The  bones  of  the  face  may  be  broken  by  direct  violence; 
and,  when  broken,  the  displacement  is  generally  by  depres- 
sion. There  will  necessarily  be  a  severe  contusion,  and  not 
unfrequently  a  wound  clear  to  the  bone.  Xo  crepitation  can 
in'  elicited,  unless  the  comminuted  fragments  can  be  made  to 
move  against  one  another.  The  evidence  of  fracture  i-  de- 

o 

rived  from  displacement,  and  that  is  almost  always  by  depres- 
sion. The  swelling,  which  arises  rapidly,  masks  the  bony 
displacement,  so  that  the  true  condition  of  the  parts  has  to 
be  ascertained  by  indentations  made  with  the  lingers. 

Although  the  malar  bone  is  very  prominent,  and  nearly 
subcutaneous,  it  is  not  easily  broken,  or  forced  out  of  place. 
In  prize  fights  the  projecting  checks  are  especially  exp 
to  blows,  yet  in  the  whole  history  of  such  "sports,"  not  an 
instance  of  a,  broken  malar  has  occurred.  I  have  never  been 
called  to  treat  a  fracture  of  this  bone,  but  if  I  had  an  accident 
of  the  kind  to  manage,  I  should  expect  to  treat  it  as  1  would 
a  depressed  zygoma.  There  is  generally  in  connection  with 
the  fracture,  a  wound  of  the  integument  covering  the  bone, 
and  through  this  an  awl-like  lever  might  be  used  to  elevate 
the  depressed  fragments. 


FRACTURE  OF  THE  SUPERIOR  MAXILLARY  BOXES. 

Fragments  by  direct  violence,  are  occasionally  detached 
from  the  front  portions  of  the  superior  maxillary  bones.  The 
nasal  or  ascending  processes,  as  has  already  been  indicated, 
may  be  broken  by  the  same  force  that  breaks  the  ossa  nasi. 

In  a  case  that  came  under  my  observation,  a  man,  in  a  fall 
from  the  loft  of  his  barn,  struck  upon  the  tire  of  a  wagon, 
and  sustained  a  fracture  of  one  superior  maxillary.  -The 
break  beginning  in  the  median  line  arid  extending  back  to  the 
incisive  and  canine  fossee,  separated  from  the  main  bone  a  seg- 
ment of  the  alveolar  arch  containing  four  teeth.  There  had 
been  a  tooth — the  first  molar — extracted,  which  perhaps  weak- 
ened the  bone  at  that  point,  and  allowed  the  fragment  the 
more  easily  to  be  turned  into  the'montli.  The  soft  palate  was 


FRACTURE  or  THE  UPPER  JA\V.  79 

not  nmcli  lacerated,  therefore  the  piece  of  bone  did  not  become 
completely  detached  from  its  connections.  The  upper  lip  was 
extensively  bruised;  and  there  were  injuries  to  other  parts  of 
the  body. 

I  had  no  difficulty  in  pulling  the  segment  of  the  alveolar 
arch  back  into  its  place,  and  retaining  it  there.  None  of  the 
teeth  were  loosened  from  their  places,  though  there  must  have 
been  some  interruption  to  their  nervous  and  vascular  supplies. 
The  wound  received  no  dressing  except  a  wiring  together  of 
the  two  front  or  incisor  teeth.  The  loss  of  a  tooth  beyond 
the  other  extremity  of  the  fragment,  prevented  the  application 
of  another  wire  at  that  point.  The  recovery  was  perfect,  no 
defect  or  deformity  following  the  injury. 

Cases  similar  to  the  one  described,  are  reported  in  several  of 
our  medical  journals,  and  by  Hamilton  and  Malgaigne  in  their 
Treatises.  In  the  treatment  of  fractures  of  the  superior  max- 
illary, the  rule  is  to  save  the  detached  parts  if  possible  ;  and 
if  the  mucous  membrane  of  a  fragment  be  not  entirely  sep- 
arated from  that  connected  with  the  main  part  of  the  mouth, 
the  union  of  the  piece  in  its  original  place,  may  generally  be 
expected.  The  separation  of  splinters  in  the  operation  of  ex- 
tracting teeth,  is  commonly  final,  there  being  no  attempt  to 
effect  consolidation  with  the  rest  of  the  bone. 

In  the  management  of  a  fracture  of  the  upper  jaw,  includ- 
ing a  segment  of  the  alveolus,  it  is  well  to  wire  the  teeth 
together  at  the  extremities  of  the  fragment,  and  then  bind 
the  inferior  maxillary  against  it,  with  bandages  around  the 
head  and  under  the  chin. 

When  a  bullet  enters  the  antrum,  and  carries  with  it  small 
pieces  of  bone,  the  cavity  must  be  cleared  of  the  missile  and 
the  detached  osseous  fragments,  or  prolonged  suppurative  ac- 
tion will  ensue.  It  is  better  to  take  care  of  such  an  injury 
well  at  first,  than  to  wait  until  the  complications  are  unpleas- 
ant, and  perhaps  dangerous.  With  a  drill  the  antrum  can  be 
entered  without  incising  the  cheek.  The  lip  is  held  up  while 
the  operator  perforates  the  cavity  of  the  jaw  above  the  roots 
of  the  teeth. 


CHAPTER   XIY. 


FRACTURE  OF  THE  INFERIOR  MAXILLARY. 


The  lower  jaw,  from  its  situation,  is  exposed  to  injury;  and 
parts  of  the  bone,  which  are  thinly  covered,  receive  blows 
with  full  force.  However,  the  inferior  maxillary,  in  shape 
and  mobility,  is  signally  protected  against  fracture.  A  heavy 
blow  directly  in  front,  tells  powerfully  upon  the  symphysis,  as 
the  bone  does  not  have  an  opportunity  to  slide  or  otherwise 
escape  the  full  effect  of  the  stroke ;  but  a  blow  upon  the  side 
of  the  jaw  is  decomposed  by  the  lateral  sliding  of  the  bone. 

FIG.  17. 


Fracture  of  inferior  maxillary  bone. 

The  under-jaw  is  weakest  at  a  point  just  in  front  of  the 
insertion  of  the  masseter  muscles;  at  least,  fracture  takes 
place  more  frequently  there  than  at  any  other  place.  Direct 
violence,  as  the  kick  of  a  horse,  is  the  common  cause  of  a 
broken  inferior  maxilla.  Boyer  maintains  that  the  solution 
of  continuity  never  occurs  just  at  the  symphysis.  In  two 
instances  I  have  seen  fracture  in  the  median  line.  Plenty 
of  similar  cases  have  been  reported.  In  adult  age  the 

(80) 


THE  INFERIOR  MAXILLARY.  81 

bone  is  very  strong  at  the  symphysis,  yet  the  frequency  of 
fracture  at  that  point  indicates  that  the  strength  of  the -bone 
may  be  overcome  by  a  powerful  blow  centrally  applied. 

The  bone  is  rarely  broken  in  two  places.  A  crushing  kind 
of  force,  us  where  the  face  is  run  over  by  a  loaded  wagon,  may 
inflict  a  double  fracture.  The  neck  of  the  condyle  is  rather 
slender,  and,  in  a  divided  muscular  action,  in  conjunction 
with  a  complication  of  forces  acting  in  a  fall,  it  may  be 
broken.  The  coronoid  process  is  so  well  protected  by  the 
zygoma  and  thick  muscles,  that  a  fracture  of  it  must  be  exceed- 
ingly rare.  The  ramus  maybe  separated  from  the  body  of 
the  bone  at  the  angle,  or  a  little  above. 

Fracture  of  the  lower  jaw  may  be  simple,  compound,  com- 
minuted and  complicated — the  nature  of  the  injury  depending 
much  upon  the  violence  sustained.  A  segment  of  the  alveolar 
arch,  taking  with  it  several  teeth,  is  occasionally  detached.  In 
such  cases,  the  gums  and  mucous  membranes  of  the  mouth 
are  lacerated. 

Bonn  gives  an  account  of  a  fracture  in  combination  with 
dislocation  of  the  lower  jaw.  The  same  force  in  one  direction 
did  not  occasion  the  double  injury,  but  a  series  of  forces  acting 
at  different  times  and  in  different  directions,  as  when  a  man, 
in  falling  from  a  high  building,  strikes  a  scaffolding  on  his 
Avav  down,  and  receives  one  kind  of  injury,  then  as 
lie  reaches  the  ground  covered  with  rubbish,  sustains  another 
kind  of  hurt  or  a  multiplicity  of  injuries.  It  would  be  diffi- 
cult to  account  for  certain  complicated  injuries,  except  on  the 
theory  of  the  action  of  a  variety  of  forces. 

A  jaw  that  has  been  weakened  by  ulceration  around  dis- 
•  •a-"d  fangs  of  teeth,  may  break  under  the  force  a  dentist  im- 
parts in  the  act  of  extracting  a  neighboring  tooth.  I  once 
saw  a  jaw  that  had  been  broken  while  a  dentist  was  extracting 
the  lower  teeth  to  prepare  the  mouth  for  an  artificial  set.  The 
bone  was  carious  at  the  point  of  fracture  ;  and  had  been  thus 
rendered  by  an  old  fang  that  was  completely  hidden  by  the 
over-growing  gum.  Suspecting  a  diseased  state  of  the  bone, 
for  the  dentist  assured  me  that  he  used  only  moderate  force, 
I  explored  the  fractured  ends  with  a  slender  dental  instru- 
ment, and  discovered  and  dislodged  the  old  fang.  Suppura- 
tion kept  up  for  three  or  four  weeks,  and  then  the  fragments 
united  as  in  an  ordinary  fracture  of  the  jaw. 
6 


82  FRACTURES. 

Muscular  action  has  been  known  to  produce  fracture  of  the 
neck  of  the  condyle.  Professor  Joseph  Pancoast  once  met 
such  a  case  in  the  Jefferson  College  Clinic.  An  old  man  suf- 
fered the  lesion  while  in  a  paroxysm  of  violent  coughing. 

Mr.  Holmes,  of  London,  exhibited  to  the  Pathological 
Society  a  specimen  of  a  fractured  portion  of  the  neck  of  the 
lower  jaw  driven  into  the  meatus  auditorius  externus.  Vio- 
lence producing  fracture  of  the  inferior  maxillary,  may  be 
sufficient  to  crush  the  bones  of  the  face,  and  to  injure  the 
brain. 

In  most  of  the  instances  coming  under  my  observation,  the 
direction  of  the  fracture  has  been  more  transverse  than  ob- 
lique. This  has  not  always  been  the  experience  of  other  ob- 
servers. Reports  of  a  great  variety  of  cases  show  that  the 
course  of  the  fracture  in  this  bone  may  be  similar  to  that  in 
the  long  bones. 

When  fracture  occurs  in  the  body  of  the  jaw,  the  symptoms 
are  plain,  and  distinctly  indicate  the  nature  of  the  injury. 
There  is  mobility  of  the  parts,  crepitus,  and  irregularity  in  the 
line  of  the  teeth  ;  the  gums  are  torn  and  bleeding,  the  mouth 
is  usually  partly  open,  the  saliva  dribbles  away,  and  the 
patient,  in  making  known  his  wants  and  sufferings,  utters 
words  without  allowing  much  motion  of  the  mouth.  One 
fragment  rarely  takes  the  same  line  as  the  other,  but  there  is 
apt  to  be  a  rocking  of  the  short  piece,  and  a  displacement 
above  or  below  the  long  fragment,  or  overlapping  as  in  frac- 
tures of  the  long  bones. 

When  fracture  occurs  in  the  ramus,  or  about  the  neck,  or 
coronoid  process  of  the  bone,  the  displacement  is  either  incon- 
siderable, or  in  such  a  situation  as  to  be  recognized  with  some 
difficulty.  The  pain  at  the  point  of  injury,  the  mobility,  and 
crepitus,  are  signs  that  might  be  expected,  and  when  the  latter 
can  be  heard  or  felt,  it  is  not  to  be  mistaken. 

Sometimes  the  bone  is  splintered  at  the  time  of  the  frac- 
ture, or  a  small  portion  becomes  carious  afterwards,  causing 
exfoliation  to  take  place  before  the  part  will  unite.  Abscesses 
forming  in  connection  with  these  cases  are  often  very  tedious 
and  difficult  to  cure. 

The  tearing  of  the  gum,  a  frequent  complication  in  fracture 
of  the  lower  jaw,  is  not  to  be  considered  fully  in  the  light  of 
a,  "  compound  "  injury,  for  the  laceration  is  within  the  mouth, 


THE  INTERIOR  MAXILLARY.  83 

so  that  the   healing-  process  is  not  much  prolonged  by  the 
wound  in  the  soft  tissues. 

The  redaction,  of  fractures  of  the  inferior  maxillary  is  not 
generally  attended  with  serious  obstacles.  Manipulation  of 
the  broken  parts  is  most  conveniently  conducted  while  the 
patient  is  sitting  on  a  stool  or  low  chair,  and  the  operator  is 
seated  behind  him.  Then  the  surgeon  with  the  patient's  head 
leaning  against  his  breast,  can  with  his  thumbs  and  lingers 
press  the  displaced  fragments  into  line.  Any  loosened  tooth 
had  better  be  removed,  lest  it  interfere  with  perfect  apposition 
of  the  fragments,  and  the  healing  process. 

The  surgeon,  leaning  over  the  patient,  as  indicated,  has  a 
good  opportunity  to  feel  any  irregularities  along  the  base  of 
the  bone,  or  want  of  harmony  in  the  dental  arches  and 
planes.  If  the  surgeon  is  unable  to  adjust  the  fragments  by 
.sitting  behind  the  patient,  he  can  have  an  assistant  take  his 
place  to  support  and  steady  the  head,  while  he,  standing  in 
front  of  the  patient,  has  a  better  opportunity  to  manipulate 
the  jaw. 

If  a  tooth  is  merely  loosened,  and  is  not  in  danger  of  getting 
oetween  the  fragments,  or  of  interfering  with  the  healing  pro- 
cess, an  attempt  may  be  made  to  save  it.  Having  had  some 
trouble  with  a  loose  tooth  I  tried  to  save  in  one  instance,  I  am 
not  so  "  conservative "  in  my  notions  in  regard  to  saving 
teeth  as  were  my  early  teachers. 

TREATMENT. — The  common  method  of  treating  fracture  of 
the  inferior  maxillary,  is  to  fix  the  lower  jaw  firmly  against 
the  upper,  either  directly,  or  by  placing  two  pieces  of  cork  be- 
t  wren  the  teeth,  and  then  applying  a  bandage  tightly  under 
the  chin  and  over  the  top  of  the  head.  The  dressing  is  to  be 
kept  on  for  four  or  five  weeks.  During  this  time  the  patient 
must  live  on  liquid  food,  or  such  as  he  can  swallow  without 
mastication.  It  is  quite  desirable  that  the  nourishment  should 
be  rich  and  stimulating,  therefore  beef,  mutton,  and  chicken 
broths,  in  which  bread  is  soaked  or  softened,  should  constitute 
a  part  of  the  patient's  diet. 

The  variety  of  "splints"  and  dressings  devised  to  treat 
fracture  of  the  inferior  maxillary,  is  greater  than  necessary. 
In  hospitals  where  gutta  percha  and  other  splint-material  is 
at  hand,  such  substances  seem  very  satisfactory  for  moulding 


84 


FRACTURES. 


FIG.  18. 


A  piece  of  pasteboard,  split  at  each 

end  toward  the  middle,    to   be 

folded  to  fit  the  chin. 


FIG.  19. 


purposes.  However,  it  is  my  design  not  to  give  undue  prom- 
inence to  means  and  methods  only  practicable  in  public  insti- 
tutions, or  in  large  cities  where  almost  any  mechanical  con- 
trivance can  be  obtained  at  short  notice  ;  but  to  make  such 

suggestions  and  give  such  di- 
rections as  may  enable  a  prac- 
titioner in  a  rural  district  to 
fix  up  his  case  satisfactorily, 
with  materials  at  command. 
A  piece  of  pasteboard  about 
eight  inches  long,  and  four  or 
five  broad,  may  be  taken  and 
split  up  the  middle  from  each 
end  to  within  an  inch  of  the 
centre.  The  material  is  then 
to  be  dipped  in  warm  water, 
to  make  it  soft  and  pliable,  arid 
folded,  as  indicated  in  the 
wood-cut.  The  splint  thus 
moulded  can  be  applied  to  the 
chin;  and  by  a  little  manipu- 
lation, it  may  be  made  to  adapt 
itself  closely  to  the  part,  so  it 
shall  give  equal  and  uniform 
support.  It  may  be  retained 
in  place  by  a  four-tailed  ban- 
dage, or  a  roller  carried  in 
front  of  the  chin,  and  around 
the  base  of  the  head  below  the 
ear,  then  across  the  top  of  the 
head  obliquely,  and  under  the 
chin  and  over  the  head  again, 
as  depicted  in  the  wood-cut. 
At  the  points  where  the  turns 
of  the  bandage  cross  each 
other,  pins  should  be  used  to 
keep  the  dressing  from  slipping  out  of  place.  Gntta  percha, 
cut  like  the  pasteboard,  and  soaked  in  very  hot  water  to  make 
it  pliable,  may  be  used  in  the  way  just  described.  A  firm 
piece  of  sole  leather  answers  an  excellent  purpose.  Tough 
bark  is  not  without  its  desirable  qualities  in  treating  fracture 


Pasteboard  folded  ready  to  be  applied 
to  the  chin. 


FIG.  20. 


Pasteboard  applied  to  chin,  and  held 
in  place  by  a  bandage. 


TUB  INFERIOR  MAXILLARY. 


85 


of  the  inferior  maxillary  wlieii  other  means  can  not  be  com- 
manded. 

The  employment  of  silver  wire  as  a  ligature  to  fasten 
together  contiguous  teeth  on  each  side  of  the  fracture,  is  the 
most  reliable  and  satisfactory  means  of  holding  the  fragments 
adjusted.  A  strong  silk  or  hempen  cord  will  do  ill  place  of 
the  silver  wire.  Even  an  iron  wire  may  be  used  in  case  no 
silver  wire  is  at  hand.  In  one  instance  coining  to  my 
knowledge,  a  piece  of  tough  iron  wire  was  used  to  twist 
together  adjoining  teeth  in  fragments  of  the  under  jaw,  and 
it  held  its  place  for  three  weeks.  At  the  end  of  that  time  no 
further  retentive  means  were  needed. 

If  silver  wire  be  used,  a  large  size,  ordinarily  employed  for 
sutures,  should  be  selected.  There  is  generally  space  enough 
between  the  teeth,  near  the  gum,  for  one  end  of  the  wire  to 
pass  readily.  A  piece  from  twelve  to  fifteen  inches  in  length 
is  long  enough.  After  one  end  is  carried  through  to  the  mid- 
dle of  the  ligature,  it  may  be  bent,  and  pushed  back  out  of 

the  mouth  between  the  two 
teeth  nearest  the  other  frag- 
ment. Then,  with  the  two 
ends  of  the  wire  in  his  hands, 
the  surgeon  can  draw  the  pieces 
of  bone  together  and  hold  them 
in  apposition,  by  twisting  the 
ends  of  the  wire  ligature 
around  each  other.  After  a 
secure  fastening  is  made  in 
this  way,  the  free  ends  of  wire 
may  be  cut  with  scissors,  down 
to  the  twist.  Finally,  the  rough 
end  of  the  fastening  may  be 
bent  with  forceps,  and  thus 
kept  from  jagging  the  lip. 
Forceps  may  be  employed  with  advantage  in  carrying  the 
wire,  between  the  teeth. 

A  silk  or  hempen  thread  may  be  passed  between  the  teeth 
by  the  aid  of  a  short  needle.  The  wire  may  be  carried  twice 
around  the  necks  of  adjoining  teeth,  with  the  view  of  greater 
strength  and  security,  but  a  single  ligature  is  generally  better 
than  two. 


Silver  wire  passed  around  two  teeth 

adjacent  to  fracture  of  jaw,  and 

ready  to  be  twisted. 


86  Fll.VCTURES. 

If  the  tooth  next  the  fracture  be  loose,  or  missing,  the  liga- 
ture may  be  made  to  surround  the  next  in  the  row. 

Where  no  teeth  exist,  the  fragments  may  be  perforated  on 
each  side  of  the  fracture,  and  a  silver  wire  ligature  employed 
to  fasten  the  pieces  of  bone  together. 

1  have  had  such  excellent  success  in  ligaturing  the  teeth, 
and  the  results  have  been  so  satisfactory,  that  I  feel  like  be- 
•  stow  ing  great  praise  upon  this  plan  of  joining  the  fragments 
in  the  treatment  of  fractures  of  the  lower  jaw.  It  permits 
five  movements  of  the  moutli,  although  mastication  is  not  to 
be  admitted.  If  the  patient  can  not  be  trusted  to  keep  the 
jaw  pretty  quiet  after  the  teeth  are  wired  together,  it  will  be 
best  to  finish  the  dressing  with  the  pasteboard  cap  for  the  chin. 
arid  the  roller  to  keep  it  in  place. 

Ivory  and  metallic  clamps  to  fit  the  chin,  and  others  to  be- 
stride the  alveolar  arch,  have  been  employed  with  success. 
Perhaps  there  may  be  instances  where  it  is  impracticable 
to  use  the  wire  suture;  and  a  chin  or  clamp  dressing  is  the 
only  means  left  which  can  be  employed.  However,  the  past«-- 
board,  gutta  perch  a,  or  leather  chin-piece,  is  never  beyond 
reach. 

I  have  seen  cases  where  all  means,  except  the  wire  ligature 
around  the  teeth,  have  failed  to  keep  the  fragments  in  apposi- 
tion and  at  rest. 

Fractures  through  the  ramus,  neck  of  the  condyle,  or  coro- 
noid  process,  can  not,  of  course,  be  treated  with  the  silver 
wire  ligature.  In  such  cases  the  chin  dressing,  with  band: 
constitutes  the  only  means  that  contribute  to  the  suppon  <>: 
the  broken  parts.  Such  fractures  are  beyond  reach,  and  the 
fragments  continue  under  the  control  of  the  masseter  and 
pterygoid  muscles.  The  coronoid  "process,  as  has  been  stated, 
is  rarely  broken  ;  and  even  when  fractured,  the  temporal  mus- 
cle, on  account  of  the  great  extent  of  its  insertion,  does  not 
generally  displace  the  fragment. 

Delayed  union  and  false-joint  are  occasional  detects  the  sur- 
geon has  to  encounter  in  the  management  of  fracture-  of  the 
lower  jaw.  One  of  the  alleged  reasons  for  these  defect-  is 
that  the  saliva  may  have  free  access  to  the  broken  surfaces, 
dissolving  and  washing  away  the  ivparative  material:  but  a 
more  acceptable  explanation  is  that  the  interior  maxillary  is 
to  some  extent,  a  floating  bone,  subject  to  motion  at  every  a«-t 


THE  INFEUIOH.  MAXILLARY.  87 

of  speaking  or  swallowing.  Want  of  steadiness  in  Iroken 
bones  always  delays  union,  or  altogether  prevents  that  result. 
In  one  of  my  cases,  complete  consolidation  did  not  take  place 
for  over  a  year  from  the  reception  of  the  fracture.  The  mo- 
bility during  the  later  period  of  the  consolidating  process,  was 
very  slight,  and  did  not  inconvenience  the  patient.  The  frac- 
ture was  through  the  symphysis,  and  the  accompanying  inju- 
ries were  so  severe  that  there  was  little  hope  of  a  recovery  for 
several  weeks. 

Allusion  has  been  made  to  the  use  of  corks  between  the 
teeth.  These  when  used  are  designed  to  keep  the  jaws  apart 
so  that  food  can  be  taken.  The  corks  should  be  wedge-shaped, 
and  channeled  above  and  below  for  the  reception  of  the  teeth. 
There  are  objections  to  any  material  used  in  this  way.  Even 
the  gutta  percha  wedges  recommended  by  Hamilton  impart  an 
unpleasant  flavor  to  the  mouth  as  long  as  they  are  worn.  In 
one  instance,  where  the  teeth  were  too  closely  set  to  allow  of 
nutrient  fluids  to  be  easily  sucked  between  them,  I  used  leaden 
wedges,  channeled  for  the  teeth,  and  curved  to  correspond 
with  the  arches  of  the  jaws.  I  was  well  pleased  with  the  part 
they  served.  These  interdental  splints  are  not  needed  in  cases 
treated  by  fastening  the  fragments  together  with  silver  wire 
inserted  between  the  teeth. 

In  the  event  of  double  fracture,  a  segment  of  one  side  of 
the  jaw  being  detached,  it  may  be  difficult  to  use  the  wire  far 
back  in  the  mouth.  However,  if  the  front  end  of  the  de- 
tached piece  of  bone  can  be  secured  by  suture  to  the  long  and 
more  stable  fragment,  the  result  will  generally  be  more  satis- 
factory than  when  treated  with  chin  splints  and  bandages. 

When  fracture  of  the  jaw  is  left  untreated  during  the  pe- 
riod of  union,  the  fragments  do  not  rest  accurately  in  appo- 
sition, but  sufficient  displacement  exists  along  the  dental 
arches  to  render  mastication  unpleasant.  Afterwards  the 
.surfaces  of  the  teeth  wear  unevenly,  and  become  liable  to 
early  decay.  Considering  how  easy  it  is  to  diagnose  fracture 
•  it  the  i  uteri  oj'  maxillary,  it  seems  strange  that  so  many  cases 
arc  overlooked,  and  allowed  to  pass  without  treatment. 


CHAPTER    XV. 

% 

FRACTURE  OF  THE   HYOID  BONE,  ETC. 


The  os  hyoides  is  exposed  not  rarely  to  one  kind  of  violence, 
viz.,  the  grip  of  an  antagonist.  Other  causes  might  be  enu- 
merated, but  the  one  mentioned  breaks  the  hyoid  bone  more 
frequently  than  all  others  together.  The  shape  of  the  bone  is 
such  that  the  thumb  on  one  side  of  the  throat  and  the  fingers 
on  the  other,  tend  to  force  the  two  great  cornua  towards  each 
other.  The  fracture  may  take  place  tli rough  the  body  of  the 
bone,  or,  as  is  oftener  the  case,  through  one  of  the  branches. 

While  the  head  is  bent  forward,  the  hyoid  bone  is  protected 
by  the  under  jaw;  with  the  head  thrown  back,  the  bone  be- 
comes exposed  to  blows,  and  other  kinds  of  violence.  Ollivier 
reports  that  a  woman,  fifty-six  years  of  age,  made  a  false  step 
and  fell,  her  head  being  thrown  forcibly  backwards.  She  re- 
ceived, from  muscular  action,  a  fracture  of  the  greater  cornu 
of  the  hyoid;  and  heard  a  distinct  crack  at  the  upper  part  of 
the  left  side  of  the  neck,  at  the  moment  she  fell.  Dr.  1'.  < ';. 
Fore,  of  Cincinnati,  had  a  case,  which  was  sustained  by  a 
direct  blow,  received  in  falling  down  stairs,  a  projecting  brick 
inflicting  the  injury. 

The  signs  of  fracture  of  the  hyoid  are  generally  wel] 
marked.  The  snap  is  audible,  and  quite  often  heard  by  the 
patient ;  the  pain,  coming  on  immediately,  is  severe,  and  is 
quickly  followed  by  notable  external  swelling  ;  discoloration, 
the  result  of  ecchymosis,  appears  sooner  or  later;  and  the 
patient  can  not  speak  or  swallow  without  occasioning  distress. 
Crepitation  can  not  always  be  elicited,  owing  in  part  to  the 
displacement,  and  in  part  to  the  difficulty  of  manipulating  the 
fragments.  The  finger  carried  back  along  the  floor  of  the 
mouth  to  the  root  of  the  tongue,  may  discover  the  rough  ends 
of  the  fragments.  The  treatment  consists  more  in  combatting 

(88) 


THE  HYOID  BOXE.  89 

inflammation,  and  enjoining  a  quiet,  easy  position,  than  in  any 
kind  of  retentive  dressing. 

In  the  event  of  displacement,  the  finger  of  one  hand  is 
pa»ed  into  the  throat,  and  the  other  hand,  externally,  assists 
in  adjusting  the  pieces.  Once  in  place,  the  fragments  are  not 
generally  drawn  out  of  position,  especially  if  the  head  he  kept 
inclined  forward,  and  in  a  state  of  repose.  The  patient  may 
have  to  he  fed  through  a  tube  for  a  few  days.  The  recovery 
is  uvnerally  complete  in  four  or  five  weeks.  Dr.  George 
Harloy,  in  Holmes'  System  of  Surgery,  reports  a  case  of  frac- 
ture of  the  hyoid  hone,  which  illustrates  the  peculiarity  of  the 
symptoms,  and  refers  to  a  bandage  employed  in  the  treatment. 
"  On  the  28th  of  March,  1856,  a  little  girl,  aged  six  years, 
while  jumping,  fell  with  her  neck  across  the  rail  of  an  iron 
bedstead.  She  was  instantly  seized  with  a  tit  of  coughing, 
great  dyspnoea,  an  inclination  to  vomit,  and  a  copious  flow  of 
saliva.  The  saliva  was  partly  tinged  with  blood.  When 
brought  to  us.  which  was  almost,  immediately  after  the  receipt 
of  the  injury,  there  was  distressing  difficulty  of  breathing,  the 
lace  was  of  a  livid  blackness,  and  there  were  all  the  other 
symptoms  of  impending  death  byapncea.  On  examining  the 
neck,  there  was  found  a  sharp  body  projecting  beneath  the 
skin.  It  was  very  angular  and  quite  moveable.  On  close  in- 
spection it  was  found  to  be  the  displaced  ends  of -the  fractured 
hyoid  bone.  One  end  of  the  body  rode  over  the  other.  By 
a  little  manipulation  the  fracture  was  reduced,  and  all  the 
symptoms  of  impending  suffocation,  together  with  the  copious 
flow  of  saliva,  etc.,  rapidly  subsided.  A  bandage  was  placed 
around  the  neck  to  keep  the  ends  of  the  bone  in  their  place ; 
and  with  the  exception  of  a  smart  attack  of  fever,  which 
lasted  three  days,  the  child  made  an  uninterrupted  recovery, 
and  without  any  deformity,  except  a  slight  fullness  caused  by 
the  callus  ;  but  even  this  after  a  time  disappeared." 

In  the  case  just  cited,  the  fragments  nearly  perforated  the 
fckin  ;  in  some  cases  the  sharp  ends  puncture  the  mucous  mem- 
brane of  the  pharynx,  pricking  and  irritating  to  an  intolerable 
degree.  Proper  reduction  consists  in  replacing  the  fragments 
so  the  ends  shall  he  at  a  distance  from  sensitive  parts.  A 
handkerchief  tied  snugly  around  the  neck  would  steady  the 
muscles,  and  prevent,  in  some  measure,  the  recurring  inclina- 
tion to  swallow. 


90  FKACTUHES. 

FRACTURE    OF    THE    LARYNGEAL    CARTILAGES. 

The  curtilages  of  the  larynx  are  sometimes  broken,  the  re- 
sult of  a  blow  or  fall  upon  the  front  of  the  neck,  or  from  a 
forcible  squeeze  of  the  throat.  M.  Lacloz  has  no  doubt  this, 
fracture  is  produced  exclusively  by  violence  inflicted  with  the 
hands  and  nails.  Plenck  has  seen  a  case  in  which  the  thyroid 
and  cricoid  cartilages  were  both  broken  by  a  fall  against  tin- 
edge  of  a  bucket.  Dr.  Frank  Hamilton  reports  a  case  arising 
from  the  kick  of  a  horse. 

Injuries  of  this  kind  are  extremely  dangerous  to  life,  in  con- 
sequence of  impediments  to  respiration,  either  immediately 
after  the  injury,  from  displacements,  and  effusion  of  blood  ; 
or,  subsequently,  from  emphysema,  and  cedematooB  infiltration. 
The  neck  has  a  swollen  and  distorted  appearance,  the  voice  is 
altered  or  entirely  lost,  and  the  act  of  swallowing  is  attended 
with  difficulty.  Cough  supervenes,  and  the  respiration  becomes 
changed  to  a  disagreeable  whistling  or  crowing.  The  emphy- 
sema, by  becoming  general,  is  a  serious  complication,  though 
the  greatest  danger  is  from  rapidly  approaching  suffocation. 

An  attempt  should  be  made  to  overcome  the  occlusion  of 
the  glottis,  by  cutting  down  upon  the  larynx,  and  even  into  it, 
that  the  infiltrated  and  cedematous  tissues  may  be  relieved. 
and  the  fragments  of  cartilage  pushed  into  place. 

A  grooved  director  or  small  elevator,  entered  through  a 
lacerated  or  artificial  opening,  is  a  serviceable  instrument  to 
raise  and  to  adjust  fragments.  The  emphysema,  it'  c-onfined 
to  regions  around  the  injury,  is  nearly  harmless,  and  may  be 
let  alone.  Punctures  to  relieve  the  infiltrated  areolar  spaces, 
will  do  some  harm  and  no  good.  The  introduction  of  a  laryn- 
geal  tube,  to  breathe  through,  might  be  of  service  in  cases 
where  suffocation  was  imminent.  Evaporating  and  anodyne 
lotions  would  be  indicated  to  subdue  or  hold  in  check  a  high 
grade  of  inflammation. 


CHAPTER  XVI. 
FRACTURE  OF  THE  VERTEBRA 


Severe  injuries  and  displacements  of  the  bones  of  the  back, 
are  generally  complicated,  fracture  and  dislocation  being  liable 
to  occur  at  the  same  time.  It  seldom  happens,  from  the  me- 
chanism of  the  vertebral  column,  that  a  simple  fracture  or 
dislocation  occurs  as  a  distinct  and  uncomplicated  lesion.  In 
the  cervical  and  lumbar  regions,  where  motion  is  not  restrained 
by  the  vertical  articular  surfaces,  dislocation  can  occur  without 
the  absolute  necessity  of  a  fracture;  but  in  the  dorsal  region, 
where  the  processes  overlap,  and  are  closely  locked,  simple 
dislocation  seems  impossible. 

In  the  management  of  injuries  about  the  extremities,  it  is 
exceedingly  important  to  draw  nice  distinctions  between  frac- 
tures and  dislocations,  that  the  proper  treatment  for  each  may 
be  applied  imderstandingly  ;  but  in  grave  injuries  of  the  back, 
the  breaking  of  the  tip  end  of  aspinous  or  transverse  process 
is  not  the  serious  part  of  the  trouble.  If  dislocation,  exist,  the 
displacement  is  to  be  overcome,  but  the  gravity  of  the  case 
depends  upon  the  condition  of  the  spinal  cord.  That  delicate 
and  important  organ  is  liable  to  be  compressed  by  the  dis- 
placement of  vertebrae ;  and  the  reduction  of  the  bones  is  more 
to  give  relief  to  the  cord  than  to  get  rid  of  a  deformity. 

Fractures  of  the  vertebral  bones  coming  from  direct  vio- 
lence, arise  mostly  from  blows;  but  they  result  from  indirect 
violence,  as  when  a  man,  in  falling  from  a  height,  strikes  upon 
the  head  or  upon  the  nates.  The  parts  hitting  the  earth  may 
escape  with  bruises,  yet  the  force  is  continued  upward,  and 
breaks  some  of  the  vertebral  bones. 

The  throat,  chest  and  abdomen  protect  from  direct  violence 
the  vertebral  chain  of  bones  in  front,  therefore  the  force  must 
come  from  the  rear,  or  from  above  while  the  bodv  is  bent 

(91) 


92  FRACTURES. 

forwards.  A  miller's  carman,  standing  in  Ms  wagon,  was  re- 
ceiving into  it  heavy  sacks  of  corn,  let  down  by  ropes  from 
the  high  story  of  a  grocery  ;  one  of  the  sacks  slipped,  and  in  ita 
descent,  struck  the  neck  and  shoulders  of  the  workman.  The 
force  fractured  the  spinal  column  at  the  fifth  dorsal  vertebra. 
A  heavy  force,  striking  the  back,  making  it  suddenly  bend 
beyond  its  ordinary  incurvation,  is  very  likely  to  wedge  off 
some  of  the  processes.  In  the  dorsal  region  the  imbrication 
or  overlapping  is  so  considerable  that  not  much  flexibility  ex- 
ists, but  in  the  cervical  and  lumbar  regions,  there  may  be  a 
good  degree  of  incurvation  without  fracture. 

EFFECT  OF  FRACTURE  UPON  THE  SPINAL  CORD.  —  A  fracture 
of  the  vertebral  column  at  any  point  between  the  occiput  and 
the  third  lumbar  vertebra,  where  the  cauda  equina  begins, 
generally  inflicts  injury  upon  the  spinal  cord  ;  and  all  the  body 
below  the  fracture  at  once  loses,  more  or  less  completely,  both 
motive  power  and  sensation.  The  great  nerve  center,  being 
impinged  upon,  or  compressed,  loses  its  functions,  and  the 
parts  depending  upon  it  for  nerve  supplies,  are  paralyzed. 
The  higher  in  the  column  the  fracture  occurs,  the  greater  tl it- 
part  of  the  body  affected — in  other  words,  the  graver  the  con- 
sequences. The  fracture  of  a  cervical  vertebra  makes  the  case 
extremely  dangerous,  owing  to  effects  upon  the  spinal  cord 
high  up,  where  the  respiratory  nerves  arise. 

The  length  of  time  a  patient  will  sometimes  live  after  a 
fracture  of  the  vertebral  column,  with  all  the  distressing  afflic- 
tions of  paralysis,  is  quite  astonishing.  Persons  have  lived 
thirty  years  under  such  unfortunate  circumstances.  Even 
with  the  fourth  cervical  vertebra  broken,  a  patient  h:is  lived 
more  than  a  year.  Mr.  Page  reports  the  case  of  a  Scotch 
gentleman,  twenty-six  years  of  age,  the  heir  to  extensive 
landed  property,  who,  while  running  on  the  edge  of  a  terrace. 
accidentally  fell  upon  a  hard  road  beneath,  a  height  of  ten  or 
twelve  feet,  and  injured  his  neck.  From  that  moment  every 
part  of  the  body,  with  the  exception  of  the  head,  was  com- 
pletely paralyzed,  the  power  of  rotating  the  head  being  all 
that  remained  to  him. 

When  a  man  has  the  spinal  cord  crushed  or  torn,  so  low 
down  that  respiration  is  not  materially  affected,  it  is  not  the 
direct  injury  and  loss  of  function  in  parts  below,  that  destroy 


OF  THE  VERTEBRA.  93 

life.  If  the  circumstances  be  favorable  the  fracture  will  con- 
solidate and  prevent  motion  dangerous  to  the  cord  if  that  re- 
main intact;  the  parts  paralyzed  may  become  atrophied,  but 
that  does  not  prevent  vital  continuance.  However,  there  are 
formidable  causes  which,  sooner  or  later,  exhaust  the  strength 
of  the  patient.  Bed-sores  on  the  hips,  coupled  with  disorders 
of  the  uriuaiy  organs,  by  combined  influences,  at  length  make 
life  succumb.  A  remarkable  feature  of  the  sores  is  that  they 
form  and  extend  with  unusual  rapidity.  In  a  few  days,  before 
nurse  or  friends  suspect  any  difficulty  of  the  kind,  large  sloughs 
have  separated  from  the  regions  of  the  sacrum  and  hips. 
The  patient,  feeling  no  pain  in  the  region,  does  not  ask  to  be 
turned  in  bed,  hence  the  prolonged  pressure  and  irritation 
upon  one  spot,  which  result  in  disorganization  of  the  tissues 
involved. 

Owing  to  the  bladder  being  deprived  of  sensation,  a  condi- 
tion which  frequently  results  in  over-distension  of  that  viscus, 
and  which  calls  for  the  repeated  use  of  catheters,  derange- 
ments of  the  mucous  lining  of  the  urinary  tracks  begin,  and 
continue  with  varying  phases  till  the  gravest  effects  are  im- 
pressed upon  the  system  already  weakened  or  seriously  im- 
paired from  other  causes. 

In  simple  fracture  of  the  spinous,  transverse,  and  articular 
processes,  as  pictured  in  surgical  works,  the  lesion  does  not 
generally  appear  formidable,  but  when  the  bodies  of  the  ver- 
tebrai  and  the  walls  of  the  spinal  canal,  are  broken,  the  pro- 
longed and  deplorable  results  tax  the  patience  of  friends  and 
the  ingenuity  of  the  surgeon. 

TREATMENT. — A  patient  with  suspected  fracture  of  the  ver- 
tebrae should  be  taken  home  in  an  easy  horizontal  position,  on 
a  door  or  shutter ;  and,  after  his  clothes  are  cut  from  him,  he 
should  be  laid  on  a  mattress.  The  surgeon  should  see  that 
extension  and  such  manipulation  be  employed  as  shall  favor 
the  return  of  any  displaced  fragments  to  their  places.  A 
slight  change  of  posture  may  be  all  that  is  needed  to  correct 
a  marked  deformity. 

Sand-bags  should  be  prepared  at  once,  and  so  employed  as 
to  sustain  the  attitude  thought  to  be  the  most  desirable. 
Common  feather  pillows  answrer  a  good  purpose  in  bolstering 
up  the  head  and  shoulders,  but  the  hips  should  be  propped  up 


94  FRACTURES. 

with  something  more  substantial.  Sand-bags  will  be  found 
useful  in  every  case,  though  the  service  of  air  and  water-pillows 
is  needed  for  parts  inclined  to  slough.  A  piece  of  buckskin 
next  to  the  integument  is  better  than  lint  or  other  line  tex- 
tures. In  the  event  of  sloughing,  the  use  of  carbolic  acid  to 
the  raw  surface  is  excellent.  The  agent  corrects  fetor,  and 
hardens  the  tissues  to  which  it  is  applied. 

It  is  still  a  question  whether  any  operative  measures  are 
ever  justifiable,  undertaken  to  relieve  compression  of  the  cord. 
The  trephine  has  been  employed  with  success  in  a  few  in- 
stances, though  there  seems  to  be  no  definite  indication  for  its 
use.  There  is  no  sign  to  distinguish  between  the  compression 
made  by  a  piece  of  bone  and  that  arising  from  effusions  into 
the  vertebral  canal.  The  diagnosis  depends  more  upon  infer- 
ence than  substantial  evidence,  therefore  the  operation  can 
never  be  performed  under  well  grounded  convictions. 

If  a  surgeon  meets  a  case  in  which  the  indications  point 
emphatically  to  an  operation,  he  should  not  hesitate  to  execute 
what  that  exceptional  ease  requires.  To  be  always  governed 
by  general  principles  deduced  from  the  majority  rule,  leaving 
no  latitude  for  exceptions,  which  may  always  exist,  would 
impose  undue  restrictions  upon  a  progressive  science. 

The  pain  aiising  from  the  fracture  of  a  vertebra  and  from 
cdnipreaaioi]  of  the  cord,  is  generally  not  severe,  therefore 
the  inexperienced  practitioner  may  overlook  the  injury.  If 
the  patient  after  sustaining  an  injury  of  the  back,  be  unable 
to  move  the  legs,  it  is  wise  to  look  after  a  lesion  of  the  spinal 
cord,  and  in  doing  so  it  is  not  best  to  turn  and  twist  the  trunk 
violently  lest  an  additional  injury  be  inflicted. 

In  some  instances  it,  is  impossible  to  determine  by  manipu- 
lation whether  fracture  exists  or  not.  During  the  examina- 
tion of  a  patient  having  a  broken  back  it  is  desirable  to  turn 
the  body  by  lifting  and  pulling  upon  the  sheet  which  is  spread 
beneath  the  trunk.  A  rolling  motion  is  thus  imparted  which 
does  not  disturb  injured  parts. 


CHAPTER    XVII. 
FRACTURE  OF    THE   RIBS,  ETC 


The  length  of  the  ribs,  their  curved  shape,  together  with 
their  articulation  to  the  sternum  by  means  of  elastic  cartilages, 
contribute  to  their  power  of  resisting  forces,  which  otherwise 
would  be  continually  causing  fracture  of  these  bones.  Even 
as  it  is,  with  all  their  advantages  for  resisting  fracture,  such 
lesions  are  extremely  common,  forming  about  one-tenth  of  all 
fractures. 

The  elasticity  of  the  ribs  varies  greatly  with  age;  the  young 
rarely  suffer  from  broken  rib,  while  in  elderly  people,  whose 
bones  have  become  unyielding  and  brittle,  the  injury  is  ex- 
ceedingly frequent. 

The  anterior  extremities  of  the  ribs  being  more  elastic  and 
less  firmly  fixed  than  their  vertebral  ends,  fractures  of  these 
bones  occur  less  often  in  front  of  the  middle  than  behind  that 
point.  A  rib  may  break  at  a  point  remote  from  the  part 
struck,  for  it  will  first  bend  to  a  certain  extent,  and  then  yield 
at  the  point  where  the  flexibility  ceases.  A  given  amount  of 
compressing  force  applied  to  the  front  of  the  chest  of  a  young 
person,  makes  a  rib  snap  away  back  near  its  angle ;  the  same 
force,  applied  to  the  same  spot  on  the  thorax  of  an  old  subject, 
breaks  the  bone  in  its  middle  or  more  anteriorly. 

A  direct  force  against  the  side  of  the  chest,  breaks  a  rib  and 
carries  the  ends  of  the  fragments  inwards,  lacerating  the 
pleurae  and  lungs.  A  force  applied  to  the  front  of  the  chest, 
renders  the  rib  more  convex,  or  hoops  it,  so  that  when  the 
fracture  occurs  the  ends  of  the  fragments  will  be  directed 
towards  the  skin,  and  away  from  the  viscera  of  the  thorax. 

If  a  person  be  thrown  forcibly  against  any  projecting  point, 
like  the  corner  of  the  table,  one  rib  is  broken  ;  but  the 
kick  of  a  horse,  or  the  crushing  force  of  a  carriage  wlioel, 

(95)  *" 


96  FllACTUIlES. 

generally  breaks  two  or  more  of  the  costal  bones.     Several 
ribs  are  broken  in  severe  injuries  of  the  chest. 

The  fracture  of  a  rib  may  be  incomplete,  the  bone  being 
simply  fissured.  In  such  cases  there  would  be  no  displace- 
ment, though  there  might  be  angular  deformity  in  a  percepti- 
ble degree.  In  complete  fracture  of  the  ribs  the  periosteum 

FIG.  22. 


may  not  be  torn,  giving  no  opportunity  for  displacement  or 
deformity.  The  intercostal  muscles  assist  in  steadying  the 
fragments  and  in  preventing  displacement;  and  the  bones  are 
firmly  fixed  both  in  front  and  behind ;  consequently  there  is 
seldom  much  shortening  or  other  displacement.  The  ends  of 
the  fragments  resting  against  each  other,  are  moved  sufficiently 
by  active  respiration  to  elicit  crepitus. 

In  the  event  of  the  thorax  being  caught  between  two  op- 
posing forces,  and  in  severe  and  complicated  accidents,  frac- 
tures may  be  produced  on  both  sides  of  the  chest ;  though  in 
the  majority  of  instances,  only  one  side  becomes  involved.  A 
rib  may  be  broken  in  two  or  more  places,  yet  the  long  bones 
of  the  extremities  suffer  comminuted  fracture  much  more  fre- 
quently. The  first  rib  being  short,  and  protected  by  the  clav- 
icle, is  seldom  fractured  ;  the  last  two,  or  floating  ribs,  on  ac- 
count of  their  natural  mobility,  scarcely  offer  resistance  suffi- 
cient for  a  force  to  act  on  them ;  the  ribs  most  frequently  frac- 
tured are  the  upper  false,  and  the  lower  true,  these  being  the 
longest  and  the  most  exposed  to  injury. 

A  simple  fracture  of  one  or  more  ribs,  uncomplicated  with 
lesions  of  the  lungs  and  other  important  structures,  is  not  a 
dangerous  injury  ;  but  when  the  pleurae  and  pulmonary  organs, 
to  say  nothing  of  the  heart  and  large  blood  vessels,  are  in- 


Or  THE  RIBS.  97 

volved  in  the  accident,  the  most  serious  eoftsequences  are  to 

be  feared.  An  analysis  of  130  cases  admitted  into  (iuy's  Hos- 
pital,during  five  years  ending  in  1800,  exemplifies  the  relative 
proportion  of  complicated  and  uncomplicated  fract;»-es  of  the 
ribs;  108  were  uncomplicated,  of  which  8  only  had  secondary 
inflammation,  proving  fatal  in  two  instances  from  previous 
old-standing  disease  :  :>'  were  complicated,  1(5  with  emphyse- 
ma, <>f  whom  lour  had  symptoms  of  piieiinionia,  though  all 
recovered,  and  of  the  remaining  twelve,  0  died  at  once  from 
fatal  collapse,  and  0  recovered.  Of  the  latter,  •"!  had  ha'inop- 
tysis  and  emphysema,  and  3  extensive  injury  and  severe  in- 
flammatory symptoms. 

The  ordinary  symptoms  of  fractured  ribs  are  quite  clear 
and  definable.  The  patient  declares  he  felt  something 
break,  or  give  way;  he  feels  acute  pain  a-t  the  seat  of  injury  ; 
and  complains  of  a  severe  stitch  in  the  side  or  catching  of 
breath  during  a  deep  inspiration  ;  the  slightest  attempt  to 
cough  disturbs  the  fracture,  and  gives  rise  to  the  sensation  of 
grating  ;  movements  of  the  ribs  on  the  affected  side,  and  even 
on  the  sound  side,  on  account  of  the  consonance  of  action,  are 
guardedly  suppressed,  and  respiration  is  carried  on  through 
the  movements  of  the  diaphragm;  the  arm  on  the  injured 
side  is  held  steady  and  in  such  a  position  as  to  relate  the  mus- 
eles  extending  from  that  member  to  the  thorax.  Crepitation 
sometimes  results  from  the  motion  of  respiration,  and  can 
generally  be  produced  by  manipulating  the  chest.  The  hands 
placed  on  each  side  of  the  supposed  seat-of  fracture,  or  on 
each  side  of  the  chest,  and  moved  alternately,  excite  sufficient 
motion  to  elicit  crepitus.  When  the  fracture  is  situated  very 
far  back,  it  is  more  difficult  to  produce  crepitation.  The  hand 
placed  upon  a  point  opposite  the  fracture,  and  made,  by  a 
sudden  impulse,  to  impart  motion  by  indirect  force,  sometimes 
causes  a  grating  of  the  ends  of  the  fragments.  The  ear 
placed  against  the  seat  of  injury  may  detect  crepitus,  the 
patient  being  requested  to  cough  while  the  auscultation  is 
made.  Crepitus,  though  an  essential  indication  of  fracture. 
is  sometimes  wanting,  and  its  absence  should  not  positively 
decide  against  the  possible  existence  of  such  an  injury.  If 
there  be  spitting  of  blood,  and  escape  of  air  into  the  cel- 
lular tissue,  the  evidence  of  fracture  is  quite  convincing,  even 
if  no  crepitus  can  be  discovered. 
7 


98  FRACTURES. 

The  prognosis  is  generally  favorable,  though  of  course  it 
will  be  modified  according  to  the  primary  and  secondary  com- 
plications. In  old  and  elderly  persons,  especially  if  they  be 
at  the  time  subject  to  bronchitis,  asthma,  or  other  forms  of 
chronic  disease,  a  guarded  prognosis  should  be  given,  even 
if  the  fracture  be  uncomplicated.  Such  individuals  often  suc- 
cumb, in  the  one  instance,  to  shock  from  their  low  state  of 
vitality  ;  and  in  the  other,  to  a  kind  of  asphyxia  from  ina- 
bility to  free  the  lungs  of  the  accumulated  mucous  secretion. 
The  pleura  is  very  liable  to  become  inflamed,  either  from  the 
fractured  ends  rubbing  against  it,  or  from  a  direct  wound 
caused  by  a  spicnlnm  of  bone  lacerating  it.  The  lungs  them- 
selves are  not  unfrequently  wounded,  and,  as  a  consequence, 
take  on  serious  inflammation.  The  cavity  of  the  chest,  be- 
tween the  pleurae,  may  get  filled  with  purulent  fluids,  and  col- 
lapse of  the  lung  result.  The  escape  of  air  from  a  wound  of 
the  lung,  may  fill  the  chest  and  compress  the  organ,  and  find 
its  way  through  rents  in  the  pleurre,  to  the  cellular  tissue  ex- 
ternal to  the  chest,  a  fact  that  may  be  known  by  a  peculiar 
crackling  felt  when  the  skin  is  pressed  on.  The  emphysema 
is  at  first  confined  to  the  side  of  the  chest,  and  is  situated  near 
to  the  fracture ;  but  gradually,  as  the  patient  goes  on  inspir- 
ing, fresh  supplies  of  air  escape,  until  it  occupies  an  immense 
extent  of  surface,  sometimes  spreading  over  the  whole  body, 
even  down  to  the  fingers  and  toes.  A  moderate  amount  of 
emphysema  is  not  especially  dangerous,  but  when  it  encroaches 
upon  the  space  needed  for  the  action  of  the  lung,  and  fills  a 
great  part  of  the  superficial  cellular  tissue  of  the  body,  the 
respiration  becomes  impeded  to  a  fearful  extent,  and  the 
movements  of  the  body,  from  the  puffy  swelling,  uncomfort- 
ably restrained. 

The  intercostal  artery,  running  just  within  the  lower  edge  of 
the  rib,  is  in  some  danger  of  being  punctured  or  lacerated  by 
the  sharp  end  of  a  broken  and  depressed  bone.  Complicated 
accidents  of  this  kind  are  exceedingly  rare,  but  quite  within 
the  range  of  possibilities. 

TREATMENT. — The  local  treatment  consists  in  keeping  the 
ribs  in  as  perfect  a  state  of  rest  as  possible.  The  best  plan  to 
accomplish  this  object,  is  to  apply  long  strips  of  adhesive  plas- 
ter, extending  from  the  spine  to  the  sternum  of  the  affected 


OF  THE  RIBS.  99 

side.  Enough  strips  an  inch  and  a  half  or  two  inches  wide, 
must  be  used  to  cover  a  space  several  inches  broad,  the  dis- 
tance covered  depending  upon  the  number  of  ribs  broken. 
These  stay  in  place  better  than  a  bandage,  and  do  not  interfere 
with  the  movements  of  the  sound-side  of  the  chest. 

In  those  cases  where  the  ends  of  the  fragments  sink  in 
toward  the  pleura,  and  compression  at  two  opposite  points  on 
the  chest  remote  from  the  injury  will  pry  the  pieces  of  bone 
outwards,  (a  manoeuvre  that  is  practicable  in  some  instances,) 
a  wide  flannel  bandage  may  be  used ;  also  compresses  at  the 
points  where  the  desired  leverage  can  be  obtained.  The  use 
of  pasteboard  and  other  splint-material  to  stay  the  broken  ribs 
and  to  impede  the  normal  motions  of  the  chest,  can  accomplish 
very  little  substantial  good. 

Some  restless  patients  refuse  to  have  any  dressing  applied, 
declaring  that  they  can  not  endure  the  confinement  imposed 
upon  the  respiratory  organs.  In  nearly  all  cases  coming  under 
my  observation  and  treatment,  the  restrictions  placed  upon 
the  movements  of  the  ribs  by  the  adhesive  strips,  have  been 
described  as  grateful.  The  sense  of  relief,  and  security  against 
irregularity  of  respiration,  have  been  acknowledged  by  patients 
thus  treated. 

Purulent  collections  in  the  cavity  of  the  thorax,  are  to  be 
removed  by  the  use  of  the  trocar,  as  in  ordinary  cases  of  em- 
pveiim.  The  escape  of  air  into  the  cellular  tissue  can  not 
always  be  prevented.  Well  adjusted  compresses  around  the 
thoracic  opening, fastened  in  place  with  adhesive  strips  and  a 
bandage,  may  arrest  the  further  issue  of  air.  In  case  the  em- 
physema become  wide-spread  and  troublesome,  punctures  may 
be  made  in  the  skin  to  let  the  air  out.  A  compressed  lung, 
from  the  collection  of  air  in  the  cavity  of  the  pleura,  has  been 
relieved  by  an  incision  made  in  the  intercostal  space  some  dis- 
tance above  or  below  the  fracture. 

To  dull  the  acuteness  of  the  pain,  and  to  arrest  the  inclina- 
tion to  cough,  the  patient  should  be  kept  under  the  influence 
of  opiates  for  several  days.  Gelseminum,  aconite,  veratrum. 
and  other  vascular  and  respiratory  sedatives  may  be  adminis- 
tered to  advantage.  Antimony  and  bloodletting  are  altogether 
too  dejfressing  and  devitalizing  to  be  employed,  though  they 
still  are  held  in  favor  amon'g  the  advocates  of  the  theory  that 
inflammation  is  an  exalted  state  of  the  vital  powers. 


100 

In  four  or  five  weeks  from  the  reception  of  a  fractured  rib, 
the  patient  so  far  recovers  that  he  can  attend  to  his  usual  avo- 
cation, when  all  treatment  may  be  suspended.  Usually  a  large 
callus  forms  at  the  seat  of  fracture.  This  excess  of  reparative 
material  is  supposed  to  depend  mostly  upon  the  constant 
motion  kept  up  by  respiration. 

FIG.  23. 


broken  i- 


"us  reparative  material  deposited  between 
lx,  in  the  course  of  the  intercostal  muscles. 


In  some  instances  the  callus  extends  obliquely  along  tin 
course  of  the  intercostal  muscles,  and  joins  several  ribs 
together  with  osseous  bridges. 

Want  of  bony  union  follows  fractures  of  the  ribs  in  a  larger 
proportion  of  cases  than  in  other  bones.  This  defect  is  pre- 
sumed to  arise  from  the  impracticability  of  keeping  the  frag- 
ments in  a  state  of  repose.  Fortunately  the  state  of  false- 
joint  is  not  attended  with  serious  inconvenience-. 

.Necrosis  of  one  or  the  other  of  the  fragments  has  been 
known  to  follow  fracture  and  to  become  a  chronic  trouble. 
At  a  proper  time  exsection  may  be  performed  to  get  rid  of  the 
dead  bone. 

FRACTURE  OF   THE  COSTAL  CARTILAGES. 

The  sterno-costal  cartilages  maybe  broken  by  forces  similar 
to  those  which  fracture  the  ribs.  In  old  age  the  cartilages 
become  ossified  wholly  or  in  part,  so  that,  by  losing  their  or- 
dinary elasticity,  they  do  not  escape  being  fractured.  The 
lesion  is  so  rare  that  it  was  scarcely  mentioned  till  i^odern 
tunes.  Magendie  having  observed  five  cases  in  two  years, 
wrote  a  thesis  upon  the  subject;  Malgaigne  states  that  he  has 


OF  THE  STERNUM.  101 

seen  only  three  cases  ;  and  that  at  the  Hotel  Dieu,  there  was 
but  one  case  in  2328  cases  of  fracture  generally.  Lie  attributes 
this  paucity  to  the  probable  omission  of  the  lesion  in  the  hos- 
pital returns. 

The  cartilage  of  the  eighth  rib  has  been  most  frequently 
broken ;  then,  those  immediately  above  it.  One  fragment  is 
liable,  to  overlap  the  other,  which  renders  the  diagnosis  easy, 
and  the  parts  may  become  united  in  that  position.  Osseous 
material  consolidates  the  fragments.  Xo  subsequent  ill  effects 
are  reported.  Though  the  callus  is  bony,  the  original  carti- 
laginous condition  of  the  broken  parts  remains  unchanged. 
The  prognosis,  in  cases  uncomplicated  with  serious  internal 
injuries,  is  favorable.  The  diagnosis,  unless  one  piece  overlaps 
the  other,  is  difficult.  Xo  true  crepitus  can  be  elicited,  but 
the  other  symptoms  are  the  same  as  in  fracture  of  the  rib. 

The  treatment  consists  in  applying  adhesive  strips,  a  foot 
or  more  in  length,  across  the  injured  spot.  The  chest  bandage 
is  not  required,  though  it  may  be  used  to  modify  the  move- 
ments of  the  thorax  in  case  pain  is  aggravated  by  the  respira- 
tory movements.  Malgaigne  found  the  bandage  useless,  but 
succeeded  in  keeping  the  fragments  in  apposition  by  the  use 
of  a  light  inguinal  truss,  with  a  soft  compress.  In  twenty  days 
the  union  was  perfect,  no  inequality  or  deformity  remaining. 


FRACTURE  OF  THE  STERNUM. 

Crushing  injuries  that  break  the  ribs  and  the  vertebrae,  are 
liable  to  fracture  the  sternum.  The  bone,  by  its  articulation 
with  the  clavicles  and  the  cartilages  of  the  true  ribs,  yields 
sufficiently  to  escape  fracture  from  ordinary  violence  ;  hence, 
uncomplicated  fracture  of  the  sternum  is  a  rare  accident.  The 
elasticity  of  the  costal  cartilages  and  the  ribs,  which  are  like 
hoops,  deadens  the  shock  and  decomposes  the  force  of  a  blow. 
Separation  of  the  manubrium  from  the  gladiolus,  is  more  fre- 
quent than  true  fracture  through  parts  wholly  osseous.  In 
advanced  age,  when  the  original  parts  of  the  bone  are  com- 
pletely ossified,  the  point  corresponding  with  the  primary  divi- 
sion between  the  upper  two  pieces,  proves  to  be  the  weakest. 
At  least,  fracture  generally  takes  place  at  that  point.  (Fig. 
24.)  The  course  of  the  fractured  line  is  across  the  bone 


102 


FRACTURES. 


FIG. 


transversely ;  and  oiie  fragment  may  be  driven  in  so  as  to  be 
overlapped  by  the  other.  There  may  be  perceptible  displace- 
ment without  one  piece  getting  behind  the  other. 

The  causes  of  the  injury  are  generally  direct 
violence,  though  persons  striking  on  the  back, 
and  having  the  body  bend  suddenly  in  a  fall, 
have  sustained  fracture  of  the  sternum. 
Chaussier  reports  two  cases  arising  from  mus- 
cular action,  during  parturition.  The  females 
were  in  labor  with  a  first  child,  and  threw 
back  their  heads,  curving  the  body  backwards. 
A  celebrated  vaulter,  whilst  bending  his  body 
backwards  in  the  feat  of  raising  a  heavy 
weight  with  his  teeth,  broke  the  sternum. 

The  symptoms  are:  a  sensation  of  breaking 
or  cracking  at  the  time  of  the  accident,  inter- 
ference with  respiration,  and  sharp  pain  at  the 
seat  of  injury.  Crepitation  may  be  produced 
by  manipulating  the  chest,  or  by  movements 
of  the  body.  The  displacement,  when  any  is 
present,  is  decisive  in  its  character,  but  if  the 
fibrous  and  fascial  investments  remain  untorn,  there  may  be 
no  overlapping  of  the  fragments.  Swelling  and  effusions  may 
obscure  the  usual  diagnostic  signs. 

Fracture  of  the  sternum  may  be  complicated  with  lacera- 
tion of  the  integuments,  anil  severe  injury  of  the  thoracic 
viscera.  The  spongy  nature  of  the  internal  structure  of  the 
bone,  favors  the  formation  of  abscess.  The  pus,  in  such  a 
case,  would  be  more  liable  to  collect  or  burrow  in  the  medi- 
astinal  space  than  in  the  cavities  of  the  pleura'.  Caries  is  not 
uncommon  after  fracture  of  the  sternum;  and  the  pus  and 
debris  may  cause  trouble  unless  they  readily  find  their  way  to 
the  surface. 

Longitudinal  fracture  of  the  sternum  is  excessively  rare. 
A  case  is  quoted  by  Malgaigne  :  A  mason,  aged  60,  fell  from 
a  scaffold  on  some  large  stones,  and  received  a  longitudinal 
fracture  of  the  sternum;  the  left  portion  overlapped  the 
right.  Reduction  was  effected  by  drawing  the  arm  to  the 
side,  and  carrying  it  backwards,  then  pressing  firmly  on  the 
middle  of  the  right  sternal  ribs,  making  alternate  movements 
from  before  backwards,  .so  a<  to  disengage,  the  fragments  ;  at 

c?    o  •-? 


Section  of  the  ster- 
num, showing 
fracture     and 
displacement. 


UF  THE  STERNUM.  103 

the  same  time  gentle  pressure  was  made  on  the  left  or  riding 
portion,  so  as  to  keep  it  on  its  own  level.  After  reduction,  a 
compress  was  applied,  and  maintained  by  a  firm  band  age. 
The  case  was  successful  at.  the  end  of  six  weeks;  no  deformity 
resulted. 

TREATMENT. — The  plan  of  treatment  to  he  adopted  in  frac- 
ture of  the  sternum,  is  to  prevent,  as  much  as  possible,  motion 
taking  place  between  the  two  portions  of  bone,  whether  they 
rest  in  apposition  or  not.  If  one  fragment  overrides  the 
other,  moderate  efforts  should  be  made  to  reduce  them,  which 
may  be  accomplished  by  manipulating  the  chest.  But  if  re- 
duction is  impracticable  by  such  means,  it  is  not  advisable  to 
use  hooks  or  elevators  to  raise  the  depressed  piece.  It  is 
found  by  experience  that  overlapping  docs  not  prevent  con- 
solidation, or  produce  serious  inconvenience,  even  if  the  pieces 
of  bone  unite,  with  one  fragment  depressed  below  the  other. 

Adhesive  strips,  applied  vertically  and  transversely,  prevent 
motion,  and  retain  the  fragments  in  contact  with  one  another. 
A  flannel  bandage  in  some  instances  where  respiration  is  at- 
tended with  pain,  may  be  used  to  surround  and  moderately 
compress  the  chest.  The  fabric  is  more  elastic  than  cotton  or 
linen,  and  one  fold  or  turn  will  not  slide  upon  another.  The 
horizontal  position,  and  moderate  doses  of  quieting  medicine, 
soon  put  the  patient  in  a  state  of  ease.  Coughing,  laughing, 
or  sneezing,  are  instinctively  avoided  by  the  patient,  therefore 
protests  against  such  acts  are  useless. 

Position  sometimes  affords  considerable  relief.  A  firm  pil- 
low or  a  large  bag  of  sand  placed  under  the  back,  to  curve 
the  trunk  in  that  direction,  puts  extension  and  counter-exten- 
sion upon  the  sternal  fragments,  favoring  reduction,  apposi- 
tion, and  repose  of  the  broken  parts. 

Many  persons  possess  such  d-el'onnities  of  the  sternum  that 
the  surgeon  called  to  an  injury  of  the  central  aspect  of  the 
chest,  might,  from  the  distorted  appearances.  be  led  to  suspect 
fracture  and  displacement  when  neither  existed. 


CHAPTER  XVIII. 
FRACTURE  OF  THE  CLAVICLE. 


The  clavicle  is  exposed  to  direct  and  to  indirect  violence  ; 
and  the  bone  breaks  from  one  influence  about  as  frequently 
as  it  does  from  the  other.  Blows  are  always  liable  to  be  re- 
ceived, and  the  body  is  often  thrown  against  unyielding  sui.- 
stances,  hitting  the  clavicle  with  direct  forces  which  result  in 
fracture.  Falls  upon  the  hand,  the  elbow,  and  especially  up»n 
the  shoulder,  impart  forces  sufficient  to  produce  fracture  ;  the 
radius,  humerus,  and  scapula  escape  by  conveying  the  shock 
or  impulse  along  to  the  next  bone  in  the  order  of  articulation. 
The  clavicle  being  slender  and  situated  disadvantageously  to 
take  the  violence  communicated  to  it,  breaks  at  its  weakest 
or  most  severely  tested  point. 

The  two  extremities  of  the  bone  are  stronger  than  its  cen- 
tral part,  and  are  connected  to  the  sternum  and  scapula  by 
means  of  protecting  ligaments,  which  render  the  ends  capable 
of  offering  much  more  resistance  than  the  middle  of  the  bone, 
which  has  no  such  support. 

When  the  fracture  is  occasioned  by  a  blow,  or  by  the  body 
coining  in  contact  with  some  hard  substance,  it  is  apt  to  be 
more  serious  in  its  nature  and  consequences,  from  the  contu- 
sion and  mischief  done  by  the  broken  ends,  than  in  fractures 
coming  from  indirect  violence.  The  situation  of  the  fractuiv 
in  the  majority  of  instances,  is  near  the  centre  of  the  bono. 
When  the  fracture  is  not  far  from  the  extremities,  the  acci- 
dent occurs  near  the  acrornion  more  frequently  than  in  the 
immediate  vicinity  of  the  sternum.  The  parts  of  the  hone 
between  the  curves  seem  to  possess  the  least  powers  of  resist- 
ance. When  the  clavicle  is  broken  near  its  middle,  (TV.  25  . 
or  between  the  middle  and  the  sternum,  the  inner  fragment  is 
usually  retained  in  its  place  by  the  ligaments,  and  count  rr- 

(104* 


OF  THE  CLAVICLE.  105 

balanced  muscular  action  ;  and  the  outer  fragment  in  some 
instances  is  drawn  a  little  downwards,  in  others  it  is  elevated 
above  the  inner.  If  the  fracture  be  outside  the  middle  of  the 


Fracture  of  clavidf  near  tlio  miili-Ilo  of  the  bone,  showing 
overlapping  and  angular  deformity. 

bone,  the  broken  ends  of  both  fragments  are  generally  drawn 
upwards.  Dr.  R.  W.  Smith,  of  Dublin,  in  his  "Treatise  on 
Fractures  in  the  vicinity  of  Joints,"  gives  a  description  of 
several  specimens  of  fractured  clavicle,  in  all  of  which  the  frac- 
ture described  was  within  two  inches  of  the  acromial  extrem- 
ity. According  to  his  illustrations,  the  broken  ends  of  both 
fragments  were  drawn  upwards,  except  in  one  or  two  instan- 
ces where  the  fracture  occurred  between  the  coraco-clavicular 
ligaments.  By  the  action  of  the  trapc/ius  muscle  the  frag- 
ments were  elevated  until  they  formed  nearly  a  right  angle 
with  each  other,  and  large  masses  of  osseous  material  (excess 
of  callus)  were  poured  around  the  seat  of  injury,  even  con- 
necting the  irregular  bony  mass  with  the  coracoid  process. 
The  coraco-clavicular  ligaments  were  either  ruptured  or  lost 
in  the  excessive  reparative  material. 

Fracture  of  the  clavicle  occurs  at  all  ages  of  life  ;  it  is  met 
in  infancy  and  extreme  old  age,  and  at  all  periods  between. 
Males  are  more  exposed  by  their  habits  and  occupations,  to 
blows,  falls,  and  fatal  accidents,  therefore  they  more  frequently 
sutler  fracture  of  the  clavicle  than  females. 

The  fracture  may  be  simple,  compound,  comminuted,  and 
complicated  ;  it  may  be  transverse,  oblique,  or  intermediate, 
partaking  of  both  varieties  so  tar  as  direction  is  concerned. 

The  prognosis,  so  far  as  prospects  for  a  good  use  of  the  arm 
are  to  be  considered,  is  favorable  ;  but  so  l-ir  as  deformity  is 
concerned,  exceedingly  unfavorable.  Few  fractures  of  the 
clavicle  unite  without  more  or  less  displacement.  Tn  most  in- 
stances there  is  shortening  either  from  angular  deformity  or 
from  overlapping.  This  common  defect  arises  from  various 
causes.  In  some  instances  the  dressing  is  not  suitable,  or  is 


106  FRACTURES. 

not  kept  well  applied  ;  in  others,  the  patient,  not  being  much 
inconvenienced  hj  the  injury,  tails  to  carry  out  the  injunctions 
of  his  surgical  attendant.  It  is  needless  to  enumerate  the 
causes  of  deformity.  The  weight  of  the  arm  dragging  upon 
the  shoulder  and  clavicle,  tends  to  produce  displacement,  un- 
less the  member  be  well  supported. 

The  symptoms  of  fracture  of  the  clavicle  are  very  evident 
in  the  majority  of  cases;  the  shoulder  falls  downwards  and 
forwards,  the  level  of  the  acromion  being  much  lower  on  the 
injured  than  on  the  sound  side.  The  shoulder  and  arm  are 
nearer  the  chest,  obliterating,  apparently,  the  axillary  space. 
One  or  the  other  of  the  fragments  will  be  unusually  prominent 
at  the  seat  of  fracture  ;  and  the  overlapping  and  displacement 
can  be  distinctly  seen  and  felt.  Crepitus  can  generally  be 
produced  by  taking  hold  of  the  shoulder  and  moving  it  up 
and  down,  while  it  is  held  outwards.  As  soon  as  the  arm  is 
left  unsupported  it  falls  downwards  and  inwards,  producing 
the  characteristic  deformities.  The  patient  experiences  great 
pain  in  these  forced  movements,  and  in  his  own  attempts  to 
move  the  limb.  He  is  unable  to  bring  the  hand  across  the 
chest  to  the  opposite  shoulder.  The  mobility  observed  at  the 
point  of  fracture,  when  the  arm  is  moved,  is  quite  decisive  as 
to  the  nature  of  the  injury.  In  most  instances  the  evidence 
of  fracture  is  so  clear  that  crepitus  need  not  be  sought.  The 
appearance  of  the  patient  before  the  clothing  is  removed,  is 
generally  such  that  an  experienced  surgeon  suspects  at  once 
the  nature  of  the  injury.  An  individual  with  a  fracture* I. 
clavicle,  is  careful  to  support  the  elbow  of  the  injured  side  in 
the  hand  of  the  sound  side.  This  is  to  take  the  weight  of  the 
limb  from  the  parts  involved  in  the  fracture,  and  to  keep  tin- 
shoulder  up  in  its  natural  position.  The  patient  is  generally 
conscious  of  the  nature  of  the  injury.  He  complains  of  numb- 
ness in  the  fingers,  which  maybe  produced  by  the  pressure  ot 
one  of  the  fragments  on  the  axillary  plexus  of  nerves.  In 
some  cases  the  pain  is  intense  and  sickening,  while  in  others. 
very  little  distress  is  experienced. 

TREATMENT. — The  numerous  contrivances  devised  and  em- 
ployed to  treat  fracture  of  the  clavicle,  indicate  (he  difficulties 
in  carrying  out  what  is  so  plainly  demanded.  The  shoulder 
is  to  be  held  upwards,  outwards  and  backwards:  to  perform 


OF  THE  CLAVICLE. 


10- 


FIG.  26. 


Unsightly  deformity  following  a 

badly  treated  fracture  of  the 

clavicle. 


this  simple  feat,  a  dozen  kinds  of  apparatus  are  in  practical 
use  ;  and  all  seem  to  bear  evidence  of  ingenuity.  If  a  patient 
would  submit  to  the  confinement  of  lying  on  the  back-  in  bed 
for  three  or  four  weeks,  the  head  being  fixed  on  a  pillow,  and 

both  arms  confined  to  the  side  of 
the  body,  no  special  apparatus  need 
be  used.  Young  ladies,  whose 
dresses  expose  the  neck,  and  in 
whom  it  is  particularly  desirable  to 
preserve  the  symmetry  of  the  clavi- 
cle, may  put  this  plan  in  practice. 
Men  and  boys  will  not  submit  to 
such  restraints,  therefore  some 
method  of  treatment  must  be  adopt- 
ed to  render  them  comfortable  dur- 
ing the  healing  process,  and  allow 
them  out-door  exercise.  A  moder- 
ate amount  of  shortening  and  nod- 
ular deformity  at  the  seat  of  frac- 
ture, is  not  often  minded  by  them,  provided  the  arm  is  at 
length  strong  and  useful. 

The  dressing  of  Dr.  Fox,  introduced  in  1828,  is  much  in 
use,  and  answers  a  very  good  purpose.  It  consists  of  a  stout 
wedge-shaped  pad,  the  thick  end  to  be  used  upwards  in  the 
axilla  of  the  injured  side,  to  serve  as  a  fulcrum  over  which 
the  arm  performing  the  part  of  a  lever  is  drawn  outwards  by 
other  parts  of  the  dressing.  A  sling,  like  a  ripped  coat  sleeve, 
made  of  strong  cloth,  extends  over  the  forearm  and  elbow, 
and  has  tapes  at  each  end;  a  stuffed  ring  is  slipped  on  the 
sound  arm  quite  over  the  shoulder.  To  this  the  tapes  of  the 
sling  are  tied,  to  lift  the  shoulder  upwards  and  outwards. 
That  the  pad  in  the  arm-pit  may  not  escape  from  its  place,  its 
upper  end  should  have  a  couple  of  tapes,  one  to  tie  to  the  ring- 
in  front,  and  the  other  behind  the  chest.  The  accompanying 
drawings  explain  the  dressing  better  than  words.  If  the  sur- 
geon, when  he  is  first  called  to  a  case,  can  not  wait  for  the 
dressing  to  be  made,  he  can  dress  the  arm  with  the  handker- 
chief, and  leave  directions  for  the  making  of  the  wedge,  ring, 
and  sleeve-sling.  The  wedge  may  be  made  of  strong  cloth, 
and  stuffed  with  cotton,  tow,  or  hair.  The  upper  or  thick  end 
should  be  packed  densely  with  the  stuffing,  that  it  may  fulfill 


108 


FRACTURES. 


FIG.  27. 


Front  view  of 


lor  tViic-t  iirc   of 


the  purpose  for  which  it  is  designed.  The  ring  may  be  stuffed 
with  cotton,  wool,  or  hair.  The  sling  needs  no  padding,  yet 
it  should  be  soft  and  yielding. 

Very  good  results  have 
been  obtained  with  the 
handkerchief  dressing. 
It  consists  in  placing  a 
long  roll  of  cloth  in  the 
arm-pit  as  a  fulcrum, 
and  using  a  common 
cotton  handkerchief  as 
a  sling  to  support  the 
elbow,  and  hold  the 
forearm  up  towards  the 
opposite  shoulder.  The 
ends  of  the  handker- 
chief are  to  be  tied 


are 
around  the  neck. 

Dr.  Lewis  modified  the 
dressing  of  Fox,  using 
the  pad  and  sling,  with 
wide  straps  to  cross  the 
chest  in  front  and  be- 
hind. It  is  not  superior 
to  the  Fox  dressing. 

Some  years  since,  Dr. 
Iluntoon  introduced  to 
the  notice  of  the  profes- 
sion a  dressing  which 
he  called  his  -•  Yoke- 
Splint,"  consisting  of  a 
yoke-shaped  piece  of 
wood,  hollowed  out  on 
the  under  surface,  so  as 
1o  fit  the  neck  and  both 
shoulders.  The  ends 
extend  some  inches  be- 
yond the  shoulder ;  and  to  which  are  attached  two  stuffed 
straps  to  pass  through  each  axilla.  These  straps  can  l>e 
buckled  so  tightly  as  to  elevate  the  shoulders,  and  carry  them 
outwards  and  backwards,  a  handkerchief  or  other  appropriate 


Fox's    drosisinj 
the  clavicle. 


FIG. 


Posto-:or  view  of  "  Fox's  <h-n-<sing  "  for  fracture  of 
the  clavicle. 


OF  TIIK  CLAVICLK.  109 

slini;1   supports  the   fore-arm    and    elbow  in  i'ront  of  the  chest. 
Such  an  apparatus  will  do  for  adults,  but  is  unfit  for  children. 

Long  strips  of  adhesive,  plaster,  carefully  applied,  constitute 
a  good  dressing  to  liold  the  arm  and  shoulder  immovable  in 
young  and  restless  patients.  The  first  piece  is  looped  at  one 
end  around  the  upper  part  of  the  arm  on  the  injured  side. 
and  then,  the  rest  of  the  strife  extends  across  the  hack,  and 
up  over  the  shoulder  of  the  sound  side,  to  the  front  aspect  of 
the.  thorax,  adhering  all  the  way.  One  end  of  the  second 
piece  of  plaster  is  stuck  to  the  posterior  aspect  of  the  arm 
on  the  injured  side,  and  passes  over  the  point  of  the  elbow, 
nlnar  part  of  forearm,  and  up  across  the  sound  shoulder  to 
the  Lack  where  it  firmly  adheres.  This  adhesive  plaster  roll 
is  easy  to  apply,  and  will  not  get  out  of  place.  If  well  put 
on  it  will  not  have  to  he  removed  or  renewed  during1  the  four 
weeks  of  healing. 

Many  years  ago  it  was  customary  to  place  a  pad  in  the 
axilla,  and  then  envelope  the  arm,  shoulder  and  chest  in  a 
very  long  bandage.  This  is  now  discarded  on  account  of  its 
confining  the  chest,  and  of  the  difficulty  of  keeping  it  in 
place. 

About  a  year  ago  I  adjusted  a  fractured  clavicle  with  hand- 
kerchiefs. The  patient  was  an  old  German,  who  received  the 
injury  by  a  fall  on  his  shoulder  in  the  street.  Upon  visiting 
him  the  second  day  I  found  the  dressing  had  been  thrown 
aside;  and  learned  from  the  old  man's  son  that  his  father  had 
refused  to  have  anything  done  in  the  way  of  treatment.  The 
patient  was  thin  of  flesh,  so  that  in  the  movements  of  the  arm 
motion  could  be  distinctly  observed  between  the  fragments. 
There  was  great  angular  deformity  caused  by  the  arm  falling 
so  low.  No  particular  pain  was  complained  of.  The  patient 
used  his  hand  every  day,  though  very  carefully.  I  called  once 
in  a  week  or  so  to  watch  the  progress  of  the  healing  process 
under  no  treatment.  There  was  so  much  motion  between  the 
ends  of  the  fragments,  that  I  was  afraid  of  non-union.  At 
the  end  of  three  weeks  from  the  date  of  the  injury,  a  pretty 
firm  callus  had  united  the  broken  ends,  though  there  was  a 
salient  projection  of  the  fragments  upwards.  In  five  weeks 
the  patient  said  he  \vas  well  as  ever,  and  claimed  credit  for 
success  in  his  let-alone  treatment. 


CHAPTER    XIX. 
FRACTURE  OF  THE  SCAPULA,  ETC. 


The  shoulder-blade  glides  easily  and  freely  in  all  directions, 
therefore  it  is  well  prepared  to  decompose  forces  or  to  yield 
sufficiently  to  escape  fracture.  Resting  upon  the  convexity 
of  the  ribs  and  muscular  cushions,  tlie  bone  rarely  suffers 
from  lesions  peculiar  to  more  rigid  and  unyielding  parts  <>t 
the  skeleton. 

The  scapula  is  deeply  covered  with  muscles,  except  at  points 
which  project  quite  prominently.  The  spine  of  the  bone,  the 
acromion  and  the  coracoid  processes,  though  subject  to  mu>- 
cular  action  and  external  violence,  escape  fracture  with  almost 
as  much  certainty  as  the  blade  itself.  Fracture  of  the  body 
of  the  scapula  occurs  in  combination  with  other  injuries  when 
the  trunk  is  severely  crushed,  as  by  the  fall  of  a  heavyweight 
upon  it,  or  by  the  force  of  moving  machinery.  A  fall  back- 
ward upon  some  projecting  point  may  produce  fracture  of  the 
blade  without  the  necessity  of  serious  complications. 

The  thin  plate  of  bone  below  the  spine  may  be  broken,  the 
fracture  being  transverse,  oblique,  irregular,  or  stellated. 
Motion  and  crepitus  are  the  two  most  important  symptoms. 
The  numerous  muscles  arising  all  along  its  flat  surfaces,  and 
crossing  the  line  of  fracture,  prevent  much  displacement. 
Sometimes  motion  of  the  arm  and  shoulder  will  cause  crepitus, 
which  may  be  felt  by  laying  the  hand  flat  on  the  dorsum  of 
the  bone  while  it  is  being  so  moved.  In  muscular  and  fat 
subjects,  and  where  there  is  little  displacement,  the  diagnosis 
is  often  attended  with  difficulty,  but  in  others  the  signs  are 
quite  plain  and  obvious.  To  ascertain  if  the  spine  of  the  bone 
be  fractured,  it  will  be  necessary  to  press  it  forcibly  with  both 
hands  while  the  patient's  arm  is  carried  backwards  and  for- 
wards, to  produce  crepitus,  and  to  disclose  the  line  of  separa- 

(1101 


OF  THE  SCAPULA. 


Ill 


FIG.  29. 


tion.  When  the  fracture  extends  through  the  body  of  the 
bone,  including  the  spine,  the  course  of  the  bony  solution 
must  be  disclosed  by  movements  imparted  to  the  fragments, 
using  the  arm  as  a  lever  to  incite  the  motions.  Occasionally 
the  body  of  the  scapula  is  broken  into  several  pieces.  In  such 

instances  it  is  impossible  to  accurate- 
ly trace  the  outlines  of  the  frag- 
ments, or  to  retain  the  fragments  in 
place  by  any  kind  of  a  dressing. 

TREATMENT  OF  FRACTURES  THROUGH 
THE  BODY  OF  THE  SCAPULA.  —  The 
fragments  having  been  reduced  as 
completely  as  possible  by  manipula- 
tion, a  broad  bandage  or  strip  of  ad- 
hesive plaster  should  be  applied 
around  the  arm,  chest  and  shoulder, 
(including  the  scapula),  so  as  to  hold 
the  broken  bone  steady  in  one  posi- 
tion, and  prevent  motion  between 
the  fragments  by  a  shifting  condi- 
tion of  the  arm.  The  elbow  should 
be  supported  in  a  sling.  Slight  deformities  from  overlapping 
of  the  fragments,  rarely  do  any  harm.  As  soon  as  consolida- 
tion takes  place,  the  functions  of  the  limb  are  regained  by  use. 
Rough  overlapping  and  irregular  callus  may,  for  a  time,  im- 
pede the  easy  action  of  the  muscles,  yet  these  contingent  de- 
fects will  not  be  permanent. 


Fracture  of  the  hlade  of  the 
scapula. 


FRACTURE   OF   THE   ACEOMION  PROCESS. 


The  acromion  process  being  the  most  prominent  part  of  the 
shoulder,  is  liable  to  be  broken  across  when  a  blow  is  received 
directly  from  above,  in  falls  upon  the  shoulder,  and  also,  per- 
haps, by  upward  pressure  of  the  head  of  the  humerus,  in  falls 
upon  the  elbow  or  hand.  The  most  frequent  accident  to  the 
acromiou,  of  a  fractured  nature,  is  the  separation  of  the  epi- 
physis  in  young  subjects.  The  accompanying  cut  illustrates 
pretty  nearly  the  line  of  separation.  In  cases  of  real  fracture, 
the  process  is  broken  nearer  the  root  than  the  apex.  The  ex- 


112 


FRACTI  •]!!•;>. 


FIG.  30. 


trenie  tip  may  be  broken  off;  and  there  may  be  genuine  frac- 
ture in  adults,  at  the  epiphyseal  line. 

The  most  frequent  cause  of  fracture  of  the  acromion  pro- 
cess, is  by  the  person  falling  side- 
ways against  some  hard  resisting 
body,  so  as  to  strike  the  top  of 
the  shoulder  as  well  as  the  side 
of  it.  Fracture  from  upward  pres- 
sure of  the  humerus  must  be  exceed- 
ingly rare.  In  cases  reported,  the 
cause  was  merely  conjectured.  The 
acromion,  in  the  dry  bone,  appears 
weak  and  unsupported,  but  in  its 
vital  state,  strengthened  with  muscles 
and  fibrous  bands,  and  sustained  by 
ligamentous  connections  with  the 
humerus  and  clavicle,  to  say  nothing 
Fracture  of  the  acromion  process.  of  ^s  sharing  in  the  gliding  charac- 
ter of  the  scapula,  it  is  capable  of  offering  great  resistance, 
and  generally  escapes  fracture. 

The  symptoms  of  fracture  of  the  acromion  are :  dropping 
of  the  shoulder,  and  inability  to  raise  the  arm  outwards,  at  a 
right  angle  with  the  trunk.  The  shoulder  loses  its  salient 
prominence,  its  extremity  being  sunk.  On  passing  the  fingers 
along  the  spine  of  the  scapula,  towards  the  tip  of  the  aero- 
mion,  a  sudden  depression  is  felt  at  the  seat  of  fracture,  and 
mobility  of  the  process  itself  can  be  perceived.  On  raising 
the  arm  so  as  to  bring  the  fragments  in  apposition,  all  the  ab- 
normal appearances  are  lost;  and  crepitus,  which  is  absent  as 
long  as  the  arm  hangs  down,  can  now  be  obtained.  "  In  a  i'at 
person,"  says  Lonsdale,  "  or  where  there  is  much  swelling 
present,  the  nature  of  the  accident  is  not  easy  to  discover, 
owing  to  the  difficulty  of  feeling  the  extremity  of  the  process, 
and  of  distinguishing  the  exact  point  at  which  the  motion 
and  crepitus  are  produced.  I  lately  saw  a  case  of  this  kind, 
where  the  patient  did  not  apply  for  relief  for  two  days  after 
the  accident;  the  whole  shoulder  was  greatly  swollen,  and 
it  was  impossible  to  say  whether  any  fracture  existed,  or  in 
what  situation  it  might  be,  if  one  were  present.  As  soon  as 
the  swelling  subsided,  however,  the  acromion  was  found  to  be 


Ol1    THE    CORACOID    PROCESS. 


113 


fractured,  and  to  be  depressed  some  way  below   the  spine  of 
the  bone." 

TREATMENT  OF  FRACTURE  OF  THE  ACROMION  PROCESS. — The 
principal  indication  is  to  support  the  elbow,  so  that  the  acro- 
mion  may  be  raised  by  the  head  of  the  humerus :  the  hand- 
kerchief sling  may  be  made  to  do  this,  care  being  taken  to 
elevate  the  elbow,  and  to  keep  the  arm  straight  across  the 
front  of  the  chest.  The  counterbalancing  action  of  the  trape- 
zius  and  deltoid  muscles,  prevents  lateral  displacement.  A 
roller  of  adhesive  plaster,  to  wind  round  the  neck  and  under 
the  elbow  and  arm,  stays  in  place  better  than  any  sling  or 
common  roller  dressing. 

The  acromion,  when  fractured,  does  not  alwaj's  unite  by 
bony  union.  The  cause  of  this  defect  is  supposed  to  depend 
upon  a  want  of  close  contact  of  the  broken  ends.  Probably 
that  has  more  to  do  with  the  lack  of  osseous  connection  than 
any  peculiarity  in  the  situation  of  the  process.  To  avoid  non- 
union, is  to  make  the  head  of  the  humerus  hold  the  extremity 
of.  the  acromion  steadily  upwards.  If  the  broken  surfaces 
can  be  brought  in  contact  and  held  there,  the  consolidation 
will  generally  be  complete  and  satisfactory. 

FRACTURE   OF   THE   CO^ACOID   PROCESS. 

FIG.  31.  The  coracoid  process  is  short  and 

very  strong;  it  is  well  protected, 
and  shares  in  the  instability  of  the 
scapula ;  indirect  violence  can  have 
but  little  influence  upon  it,  therefore 
when  broken,  the  process  must  be 
separated  by  a  blow  or  direct  fprce 
of  some  kind.  The  process  derives 
some  support  from  the  coraco-cla- 
vicular  ligaments,  and  is  sheltered 
in  its  position  by  the  clavicle  and 
the  head  of  the  humerus. 

When    the    coracoid    process    is 
broken,  the  nature  of  the  injury  is 

Fracture  of  the  coracoid  process.        discovered      by       the       displacement 

downwards  and  forwards.     The  separated  process  of  bone  is 
displaced  by  the  action  of  the  three  muscles  that  are  attached 


114 


FRACTURES. 


to  it ;  motion  in  the  process  may  be  observed  when  the  arm 
is  moved  in  various  directions.  Crepitus  can  not  be  discovered 
unless  the  arm  is  so  held  as  to  relax  the  muscles,  allowing  the 
broken  surfaces  of  the  fragments  to  come  together.  Manipu- 
lation may  then  produce  the  grating  sound.  In  injuries  about 
the  shoulder,  the  diagnosis  is  often  made  out  by  carefully  ob- 
serving the  relative  positions  of  the  prominent  points.  The 
distance  between  the  acrornion  and  the  coracoid  proce>-< •-. 
measured  with  the  fingers  and  the  eye,  as  compared  with  that 
found  in  the  sound  shoulder,  is  quite  important  in  forming  a 
conclusion,  especially  in  distinguishing  fracture  of  the  cora- 
coid process  from  fracture  of  the  neck  of  the  scapula. 

TREATMENT. — A  sling  for  the  arm,  whether  it  be  a  sleeve,  a 
handkerchief,  or  the  roller  plaster,  is  the  only  dressing  needed. 
This  apparatus  is  designed  to  support  the  arm  for  the  purpose 
of  relaxing  the  biceps,  coraco-brachialis,  and  pectoralis  minor 
muscles.  Bandages,  compresses,  etc.,  are  not  required. 


FRACTURE  OF  THE  NECK  OF  THE  SCAPULA. 


FIG.  32.  9  The  accompanying  diagram  shows 

pretty  clearly  what  is  meant  by 
fracture  of  the  neck  of  the  scapula  ; 
it  exhibits  the  line  of  fracture 
somewhere  near  its  occurrence, 
taking  with  the  free  and  separated 
piece,  the  coracoid  process  and  the 
glenoid  cavity  and  rim,  and  leaving 
joined  to  the  blade  or  body  of  the 
scapula,  'the  spine  of  the  bone  and 
its  terminal  acromiou  process.  If 
the  dried  bone  be  examined,  it  will 
be  readily  seen  where  this  isthmus 
or  narrowed  place  is.  The  con- 
striction  makes  the  scapula  appear 
weak  at  that  part  of  the  bone,  but  facts  do  not  sustain  this 
view  in  regard  to  fragility.  There  are  very  few,  if  any,  speci- 
mens in  the  cabinets  of  Europe  or  America,  showing  that 
this  fracture  has  occurred.  Several  surgeons  competent  to 


w  .   , 

Fracture  of  the  neck  of  the  scapula. 


.NECK  OF  THE  SCAPULA.  115 

recognize  the  injury  have  met  with  the  fracture  in  the  living 
subject.  Duverney  had  an  opportunity  to  examine  one  case 
in  a  woman  who  was  killed  on  the  spot  from  other  injuries; 
lie  says,  "On  examining  the  left  arm,  I  thought  it  was  dislo- 
cated; I  made  an  incision  through  the  integuments  and 
muscles,  and  opened  the  capsule;  the  head  of  the  humerus 
occupied  the  cavity,  but  I  then  discovered  the  fracture  of  the 
neck  of  the  scapula." 

While  a  student  of  medicine,  a  young  man  came  to  the 
office  of  my  preceptor,  for  treatment.  The  patient  had,  a  few 
minutes  before,  fallen  against  a  tree  and  pile  of  stones,  while 
playing  foot-ball.  lie  supported  the  arm  of  the  injured  side 
with  the  hand  of  the  sound  side,  as  a  person  will  who  has  a 
fracture  of  the  elavicle  or  dislocation  of  the  shoulder.  After 
removing  the  clothing  from  the  upper  part  of  the  body,  I< 
thought  I  recognized  a  dislocation  of  the  right  shoulder,  and 
proceeded  to  reduce  it  in  the  usual  way  by  manipulation. 
There  was  no  difficulty  in  restoring  the  arm  to  its  natural 
position,  but  it  would  not  stay  there;  the  head  of  the  humerus 
would  immediately,  if  not  prevented,  slide  into  the  axillary 
space,  leaving  a  hollow  beneath  the  acromion.  I  tried  to 
divine  the  cause  of  this  perverse  state  of  things,  and  conjec- 
tured that  the  head  of  the  humerus  did  not  slip  back 
through  the  rent  in  the  capsular  ligament,  but  in  some  way 
folded  the  ligament  in  front  of  itself  while  returning  to  the 
joint.  I  was  so  certain  of  this  condition  that  I  considered 
the  propriety  of  enlarging  the  rent  with  the  point  of  a 
knit'e  carried  through  the  soft  parts,  down  to  the  capsule. 
Fortunately  I  did  not  put  the  rash  thought  into  execution, 
but  began  anew  to  consider  the  case.  The  arm  was  not  rigid 
as  it  usually  is  when  the  shoulder  is  dislocated ;  but  the  limb 
had  the  mobility  common  to  a  fracture  injury.  Great  pain 
attended  the  manipulations,  and  the  tissues  about  the  joint 
were  soon  swollen  so  as  to  render  obscure  some  points  that 
were  at  first  quite  prominent.  However,  I  began  to  search 
for  proofs  of  a  fracture,  and  looked  at  a  dried  scapula  and 
humerus,  to  help  my  diagnostic  powers.  The  formation  of 
the  neck  of  the  scapula  suggested  what  might  be  the  nature 
of  the  injury.  I  then  turned  to  the  patient,  and  hunted  for 
the  coracoid  process.  I  found  it  he,ld  the  same  relative  posi- 
tion to  the  head  of  the  humerus  that  it  normally  did,  but  it 


116  FRACTURES. 

was  a  long  way  too  far  from  the  acromion  which  remained 
immovable  in  its  usual  place.  I  then  reduced  the  head  of  the 
humerus  to  its  normal  position  beneath  the  acromion,  and 
found  that  the  coracoid  process  had  followed  the  head  of  the 
humerus,  taking  its  place  on  the  inside  of  the  joint,  at  a 
proper  distance  from  the  acromion.  To  verify  the  new  diag- 
nostic conclusion,  I  moved  the  shoulder  back  and  forwards, 
causing  distinct  crepitation  ;  and  allowed  the  displacement  to 
occur  again,  in  order  that  I  might  carefully  note  the  relative 
position  of  the  coracoid  process  to  the  humerus  and  acromion. 
Every  point  in  the  diagnosis  became  so  plain  that  there  conld 
be  no  mistaking  any  one  of  them.  The  neck  of  the  scapula 
was  broken,  and  no  other  injury  existed. 

In  the  treatment  I  used  a  firm  pad  in  the  axilla,  to  keep  the 
head  of  the  humerus  away  from  the  chest,  and  held  the  elbow 
upwards  with  a  sling.  I  also  fastened  the  arm  to  the  side  of 
the  chest,  to  obviate  motion  at  the  seat  of  injury.  In  four 
weeks  the  dressing  was  removed,  and  gentle  motion  allowed 
to  the  arm.  The  broken  surfaces  in  this  kind  of  fracture  are 
small,  therefore  the  apposition  of  fragments  ought  to  be  per- 
fect, and  the  motion  as  much  restrained  as  possible.  Fox's 
dressing  for  broken  clavicles  is  a  desirable  appliance  for  treat- 
ing fracture  of  the  cervix  scapulae. 

The  two  strips  of  adhesive  plaster,  each  two  inches  wide 
and  a  yard  long,  so  useful  in  treating  fracture  of  the  clavicle. 
are  well  adapted  to  retain  the  shoulderin  place  while  treating 
fracture  of  the  scapula  of  any  variety.  A  loop  a  little  larger 
than  the  arm  is  made  to  encircle  the  limb  near  the  shoulder, 
and  the  rest  of  the  strip  crosses  the  back  and  passes  over  the 
shoulder  to  the  chest.  This  is  to  hold  the  shoulder  outward 
and  backward.  And  the  other  strip,  which  is  made  to  adhere 
to  the  posterior  aspect  of  the  arm,  the  elbow,  and  the  ulnar 
part  of  the  forearm,  is  to  cross  the  sound  shoulder  and  read; 
down  upon  the  back,  crossing  the  first  strip.  It  is  well  to 
split  this  second  strip  where  it  passes  the  point  of  the  elbow. 
The  dressing  keeps  every  part  of  the  arm  and  shoulder  snug 
and  steady. 


CHAPTER    XX. 


FRACTURE  OF    THE  HUMERUS 


FIG.  33. 


Anatomically  the  humerus  is  divided  into  the  head,  neck, 
tuberosities,    shaft,   and    condyles ;    surgically,   the   bone   is 
divided  into  the  upper,  middle,  and  lower  thirds,  and  it  has  a 
surgical  neck  below  the  tuberosities.     The  anatomical  neck  is 
marked  by  a  slight  constriction  between 
the    round   head  arid    the  tuberosities. 
The   condyles  make  up  the  lower  ex- 
tremities of  the  bone,  including  the  ar-' 
ticular  surfaces,  and  the  lateral  projec- 
tions which  can  be  felt  so  prominently 
beneath  the  skin.  The  thin  crests  which 
extend  from  the  condyles  upwards  until 
they  are  lost  in  the  shaft  of  tne  bone, 
are  called  condyloid  ridges.     The  shaft 
of  the  humerus  extends  from  the  tuber- 
osities to  the  condyles.     A  deep  groove 
between  the  tuberosities,  is  occupied  by 
the  tendon   of   the  long   head  of  the 
biceps.    This  brief  description,  together 
ith  the  accompanying  diagram,  brings 

2.  upper  third ;  3,' middle  third ;,  j  i?  .1  i-       •.•  .•  ..i 

flower  third;  u,  internal  uon- to  mmd  many  ot  the  peculiarities  ot  the 

dyle ;  0,  external  condyle.  ,  -,          .,,  ... 

bone,  and    will  save  calling  attention 
repeatedly  to  each  part  involved  in  fractures  of  the  humerus. 

FRACTURE  AT  THE  ANATOMICAL  NECK. 

Pathological  museums  and  autopsies  furnish  indisputable 
evidence  of  an  occasional  fracture  through  the  upper  extrem- 
ity of  the  humerus,  at  a  point  where  the  bone  is  strong  and 
well  protected  from  external  injuries.  The  fracture  alluded 

(117) 


118  FRACTURES. 

to  is   within  tlie  capsular  ligament,  no   muscles  having  any 
connection  with  the  articular  fragment. 

The  lesion  is  generally  produced  by  falls,  the  shoulder  coin- 
ing in  direct  and  violent  contact  with  the  ground  or  some  hard 
substance.  In  rare  instances  the  evidence  seems  to  be  that 
givat  force  conveyed  upward  from  the  hand  and  elbow,  in  falls 
upon  those  parts,  has  resulted  in  separating  the  head  of  the 
hunierus  from  the  remainder  of  the  bone. 

In  the  event  of  impadion,  a  condition  in  which  the  end  of 
one  fragment  is  driven  into  the  cancellated  tissue  of  the  other, 
the  broken  structures  lend  support  to  each  other,  and  by  their 
intimate  relation  favor  osseous  union  of  the  fragments.  If 
there  be  no  impaction,  the  head  of  the  humerus  is  a  lo<»<- 
piece  of  bone  entirely  within  the  capsular  ligament,  cut  off 
from  nutritive  supplies,  and  free  to  move  in  every  direction. 
even  turning  over  so  as  to  present  its  articular  surface  to  the 
broken  end  of  the  lower  or  long  fragment.  Cases  a  re  reported 
in  which  the  detached  head  of  the  humerus  has  become  united 
to  the  shaft  of  the  bone  in  every  conceivable  attitude.  In 
rare  instances,  no  consolidation  nor  union  of  any  kind  has 
taken  place  between  the  fragments,  but  the  head,  of  the  bone 
has  continued  in  the  joint  as  a  foreign  body. 

Bony  union  is  effected  in  the  majority  of  cases,  yet  with  an 
excess  of  reparative  material  about  the  broken  end  of  tin- 
lower  fragment,  and  with  such  irregularities  of  surface  thai 
the  function  of  the  joint  is  impaired. 

The  symptoms  of  fracture  at  the  anatomical  neck  of  the 
humerus  are  mostly  those  attendant  upon  fractures  of  other 
bones.  Pain,  swelling,  and  inability  to  raise  the  hand,  are 
common  signs  ;  the  flattening  of  the  shoulder,  when  present. 
may  lead  to  the  suspicion  that  a  dislocation  exists,  therefore 
the  distinctive  features  of  the  two  injuries  must  be  carefully 
compared.  The  displacement  attendant  upon  fracture  is  easily 
overcome,  yet  the  deformity  is  at  once  reproduced  as  soon  as 
the  limb  is  left  to  itself;  a  dislocated  bone  is  not  readily  re- 
turned to  place,  but,  having  been  restored  to  its  normal  posi- 
tion, it  will  stay  there. 

After  fracture  of  the  anatomical  neck  of  the  humenis.  the 
arm  is  excessively  mobile,  and  falls  or  hangs  powerless  l.y  the 
side  of  the  body;  the  depression  beneath  the  acromion  is  not 
so  great  as  in  dislocation  :  and  in  rare  instances  the  detached 


OF  THE  TUBEROSITIES. 


119 


head  of  the  humerus  can  be  fixed  with  the  lingers,  so  that 
crepitus  can  be  elicited,  in  dislocation  of  the  shoulder  the 
arm  is  rigid,  with  the  elbow  standing  off  from  the  side. 

The  (reuttnent  for  fracture  through  the  anatomical  neck  of 
the  liumerus,  is  quite  the  same  as  in  all  the  fractures  that 
occur  about  the  shoulder-joint.  The  axillary  pad  as  a  fulcrum, 
the  arm  as  a  lever,  and  slings  to  force  the  displaced  parts  into 
position  and  to  keep  them  there,  comprise  a  suitable  dressing. 
To  prevent  motion,  the  arm  should  be  bandaged  to  the  side. 
The  sling  or  handkerchief  to  support  the  elbow  and  arm 
should  not  force  the  humerus  powerfully  upwards.  As  the 
excessive  reparative  material  sent  out  from  the  lower  frag- 
ment is  sure  to  impede  the  movements  and  impair  the  func- 
tions of  the  joint,  the  surgeon  should  announce  in  advance, 
to  the  patient,  what  ma,y  be  expected  in  the  way  of  a  cure. 
Passive  motion,  begun  about  four  weeks  after  the  accident, 
may  help  to  restore  the  usefulness  of  the  joint. 


FIG.  34. 


FRACTURE  OF  THE  TUBEROSITIES. 

Direct  violence  and  muscular  action  are  the  only  agencies 
that  separate  the  tuberosities  of  the  humerus  from  the  body 
of  the  bone.  Accidents  of  this  kind  are  exceedingly  rare, 
and  liable  to  be  confounded  with  other  in- 
juries about  the  joint.  In  dislocation  of  the 
head  of  the  humerus,  the  three  powerful 
muscles  inserted  into  the  greater  tuberosity, 
may  detach  the  lump  of  bone  to  which  they 
are  connected.  In  the  dislocation  outwards, 
the  lesser  tuberosity  may  be  fractured  in  the 
same  way,  by  the  action  of  the  subscapularis. 
A  satisfactory  diagnosis  could  not  be  made 
out  in  such  injuries  unless  the  bony  tubercles 
can  be  moved  independently  of  the  remain- 
der of  the  bone.  Pain,  swelling,  and  aver- 
sion to  movements  of  the  arm,  might  cause 
the  surgeon  to  suspect  the  existence  of  frac- 

Carved  splint  for  the  arm,  .    . 

andhmged  toita  shoul-  tUl'C,    DUt    the    SUSplClOll     WOtlld    not    DC  WCIl 

founded  unless  the  fingers  could  feel  the  de- 
tached fragment,  and  make  it  grate  against  the  surface  from 
which  it  was  detsiched. 


120 


FJRACTURES. 


The  indications  in  the  treatment  are  to  keep  the  arm  and 
shoulder  at  rest  for  three  <>r  four  weeks.  A  concave  splint 
that  fits  the  shoulder,  may  be  used  to  cover  the  injured  re- 
gion ;  and  a  sling  employed  to  fasten  the  arm  to  the  front  of 
the  chest. 


FRACTURE    OF     THE    SURGICAL    NECK    OF    THE 

HUMERUS. 

The  constricted  portion  of  the  shaft  of  the  humerus,  just 
below  the  tuberosities,  is  a  common  seat  of  fracture.  The 
line  of  separation  is  above  the  insertion  of  the  pectoralis  major 
and  latissimus  dorsi  muscles  ;  and  is  usually  more  transverse 
than  oblique  in  direction.  The  amount  of  displacement  is 
considerable,  but  varies  in  different  cases.  In  characteristic 
examples  the  upper  fragment  is  tilted  upwards  and  outwards 
by  the  action  of  the  muscles  inserted  into  the  greater  tuber- 
FIG.  35.  osity,  the  lower  fragment  is  drawn  inwards 

towards  the  axilla,  by  those  inserted  into  the 
bicipital  groove,  while  the  various  muscles  ex- 
tending from  the  scapula  to  the  humerus  below 
the  line  of  fracture,  produce  shortening. 

The  symptoms  are  generally  very  evident 
and  not  liable  to  be  mistaken  for  dislocation. 
When  the  arm  is  rotated,  the  head  of  the 
humerus  remains  motionless  in  the  glen<»id 
cavity.  The  mobility  of  the  shaft  or  lower 
fragment  is  marked,  and  crepitus  is  distinct 
when  extension  is  made,  or  the  broken  ends  of 
bone  are  moved  while  in  apposition.  Frac- 
ture at  the  line  of  junction  of  the  epiphysis, 
in  young  subjects,  resembles  true  fracture 
through  the  surgical  neck  of  the  bone  in  old 
subjects.  The  only  discoverable  difference  is 
a  less  marked  crepitation  in  the  cartilaginous 
separation.  Fracture  through  the  surgical  neck  of  the 
liumerus,  in  adults,  is  generally  a  half  inch  or  more  below  the 
line  where  separation  of  the  epiphysis  occurs  in  the  young. 

If  the  injury  be  not  seen  until  the  parts  have  become  ex- 
cessively tender,  and  much  swelling  has  supervened,  fracture 
through  the  surgical  neck  will  elosely  ivscmUle  dislocation  of 


Fracture  through  the 
surgical  neck  of  the 
humerus. 


OF    THE    IIUMEIIUS. 

the  shoulder.  However,  in  case  of  doubt  and  uncertainty,  the 
patient  may  be  put  under  the  influence  of  chloroform,  when 
the  nature  of  the  lesion  can  be  determined.  In  case  of  frac- 
ture, the  space  beneath  the  acromion  will  be  found  filled  with 
the  head  of  the  bone  ;  the  humerus  will  not  stay  reduced,  but 
slide  towards  the  axillary  space  as  soon  as  left  to  itself;  and 
great  mobility  at  the  seat  of  injury  will  be  observable.  All 
of  these  signs  present  unequivocal  evidence  of  the  existence 
of  fracture. 

From  a  consideration  of   the  anatomy  of  the   region,  it 
would  seem  that  a  fracture  through  the  surgical  neck  of  the 
bone   could  not  take  place  without  marked  displacement  and 
deformity.     In  a  small  proportion  of  instances,  however,  there 
FIG  36  is  no  perceptible  disjunction  of  the 

fragments,  a  state  of  apposition 
which  is  probably  favored  by  the 
interlocking  of  serrations  in  the 
broken  ends,  and  by  the  restraining 
influence  of  the  tendon  of  the  long 
head  of  the  biceps.  Malgaigne 
rarely  met  with  displacement, 
though  in  this  he  differs  widely 
from  other  experienced  observers. 

TREATMENT. — It  is  not  always  easy 
to  reduce  the  fragments  to  a  state 

A  wovenwire  splint  extending  from  the  c            <?                         -.•                   •                  .-i 

top  of  the  shoulder  to  the  ends  of  the  OI    perfect  appOSltlOU,  OWlUg  to  the 

fingers.  It  is  useful  to  obviate  motion  i                           ,.      .  i                           n 

between    the    fragments    in  treating  Shortness    Ot     the    Upper   fragment, 

fractures  of  upper  end  of  humerus.  TIT                         •              >     i 

and  the  diverse  action  ot  the  mus- 
cles attached  to  the  two  fragments.  Extension  and  manipula- 
tion, aided  when  necessary  by  the  relaxing  effects  of  chloro- 
form, will  generally  restore  the  broken  ends  to  their  proper 
places.  A  roller  bandage  may  be  used  to  envelope  the  limb 
from  the  fingers  to  the  shoulder,  to  restrain  muscular  twitch- 
ings  and  to  prevent  congestion  and  swelling,  yet  this  is  not 
absolutely  necessary.  The  primary  bandage,  as  this  is  some- 
times called,  is  going  more  and  more  out  of  use.  A  concave 
shoulder  splint,  made  of  leather,  gutta  percha,  carved  wood 
with  a  hinge,  or  woven  wire  bent  and  soldered  to  fit  the  parts, 
is  quite  essential  for  the  outside  of  the  limb.  Two  or  three 
short  board  splints  may  be  padded  and  laid  on  the  inside  of 


122  FUACTUUDS. 

the  arm,  read  ling  from  the  axilla  to  near  the  condyles.  These 
including  the  one  that  caps  the  shoulder,  may  be  fastened  in 
their  places  with  tapes,  or  bandages.  A  firm  compress  is 
placed  in  the  axilla,  to  prevent  the  upper  extremity  of  the 
long  fragment  from  inclining  too  much  inwards,  and  a  band- 
age fastens  the  elbow  to  the  side  of  the  body.  The  weight 
of  the  arm  is  to  be  left  free  to  act  as  extending  force.  A 
handkerchief  dropped  from  the  neck  is  always  convenient  for 
the  hand  to  rest  in.  No  sling  should  be  employed  to  support 
the  elbow  or  weight  of  the  arm. 

It  must  be  borne  in  mind  that  ordinary  dressings  for  frac- 
tures through  the  middle  third  of  the  shaft  of  the  numeric. 
and  which  reach  only  about  as  high  as  the  seat  of  the  injury, 
are  not  efficacious  in  restraining  motion  between  the  frag- 
ments. Such  dressings  get  no  hold  upon  the  upper  fragment 
and  the  scapula,  therefore  they  can  not  steady  the  parts  and 
prevent  mobility. 

There  is  some  danger  of  false-joint,  especially  if  motion  at 
the  line  of  separation  be  not  thoroughly  restrained.  It  is 
found  that  a  fracture  through  the  surgical  neck  of  the  hunn-- 
rus,  does  not  become  consolidated  as  soon  as  fractures  lower 
down  in  the  bone.  The  delay  may  be  charged  to  the  mobil- 
ity, for  the  more  quiet  the  fragments  the  sooner  is  the  healing 
process  accomplished. 

FRACTURES   OF   THE   SHAFT   OF   THE   HUMEKUS. 

All  fractures  occurring  between  the  surgical  neck  of  the 
humerus  and  the  condyles  of  the  bone,  are  commonly  spoken 
of  as  fractures  of  the  shaft  of  the  os  humeri.  Such  lesions 
are  extremely  easy  to  recognize,  and  are  not  usually  difficult 
to  treat.  There  is  no  joint  near  to  mask  the  injury,  nor  com- 
panion bone,  as  in  the  fore-arm  and  leg,  to  obscure  the  diag- 
nosis, or  to  modify  the  treatment. 

Fractures  of  the  shaft  arise  from  direct  and  indirect  foiv-  : 
a  direct  force  usually  comes  in  the  shape  of  a  blow,  or  a  fall 
upon  some  hard  substance  ;  the  indirect  acts  upon  a  part  ot 
the  bone  remote  from  the  point  struck,  as  when  a  person  falls 
with  the  arm  extended  from  the  body,  the  elbow  being  the 
part  that  receives  the  shock,  Imt  the  shaft  of  the  luunerns, 
several  inches  from  the  point  hit,  may  U-  the  part  to  yield. 


OF  THE  HUMERUS.  12l> 

Direct  violence,  besides  breaking  the  bone,  commonly  inflicts 
more  or  less  injury  to  the  soft  parts,  which  is  manifest  in  the 
bruising,  discoloration,  and  ecchymosis;  the  indirect  force 

seldom  produces  much  disturbance  to  the 
FIG.  37.  f  ••••**  .a.     * 

tissues   in    the   vicinity  ot   the   fracture, 

though  at  the  point  receiving  the  shock, 
there  maybe  serious  contusions.     Muscu- 
lar action  is  often  sufficient  to  fracture 
the  humerus.     I  once  treated  a  lad's  arm 
which  was  broken  while  in  the  act  of 
throwing  a  stone.     The  patient  heard  the 
bone    "  snap   like   the   break   of    a   dry 
stick,"  and  his  arm  fell  powerless  to  his 
side.     The  fracture  was  near  the  junction 
of  the  lower  with  the  middle  third  of  the 
bone.     Fractures   from   muscular   action 
are  not  uncommon  ;  cases  happening  in 
different  parts  of  the  country  are  con- 
*!  stantly   being   reported    in   the   medical 
journals.     It  may  be  remarked  that  there 
is  no  particular  point  in  the  shaft  of  the 
humerus  that  gives  way  to  muscular  force,  for  reported  cases 
show  that  fractures  from  such  causes  occur  at  any  point  ex- 
cept through  the  articulating  extremities. 

The  displacement  following  fracture  of  the  shaft  of  the 
humerus,  is  not  always  appreciable,  for  the  fractured  surfaces 
may  remain  in  contact,  the  serrations  so  interlocking  as  not 
to  be  easily  moved  from  their  apposition.  In  most  instances, 
however,  the  contact  is  lost,  and  the  muscles  draw  the  frag- 
ments past  one  another.  In  some  instances  the  angular  de- 
formity is  great  when  there  is  no  shortening;  and  the  defect 
produced  by  rotating  one  fragment  upon  the  other,  may  cause 
a  more  marked  and  awkward  defect  than  either  of  the  distor- 
tions just,  mentioned. 

The  distinctions  between  fractures  above  and  fractures  below 
the  insertions  of  certain  muscles,  so  far  as  the  deformity  is 
concerned,  are  of  not  much  practical  importance.  The  diag- 
nosis is  extremely  easy  whether  the  line  of  separation  is  trans- 
verse or  oblique,  or  the  broken  end  of  the  lower  fragment 
iv<N  upon  the  inside  or  the  outside  of  the  other,  in  the  over- 
lapping. 


124 


RACTURES. 


FIG.  38. 


TREATMENT.  —  The  fragments  having  been  adjusted,  i\mi 
small,  straight,  well-padded  wooden  splints  should  be  applied, 
one  on  each  side  of  the  arm,  extending  several  inches  above 
and  below  the  seat  of  fracture,  and  retained  in  place  by  means 
of  tapes  tied  around  all.  Over  the  whole,  including  arm, 
splints,  and  tapes,  a  roller  bandage  ought  to  be  applied  as  it 
gives  support  to  the  dressing  that  can  not  be  obtained  by 
straps  and  buckles,  or  a  multiplicity  of  ties.  A  primary 

bandage,  reaching  from  the 
fingers  to  the  shoulder, before 
the  splints  are  applied,  is  not 
necessary,  although  some  sur- 
geons contend  that  this  is 
valuable  to  prevent  excessive 
swelling  and  muscular  twi tell- 
ings. The  splints  may  be  pad- 
ded with  cotton,  or  wrapped 
with  soft  muslin.  A  sling 
dropped  down  from  the  neck 
is  convenient  for  the  fore-arm 
or  hand  to  rest  in.  All  me- 
chanical contrivances  for 
keeping  up  extension  and 
counter-extension,  as  Swinburne's  apparatus,  are  open  to  such 
serious  objections  that  they  have  fallen  into  disuse.  The 
weight  of  the  arm  counteracts  the  retraction  of  the  muscles. 
If  there  be  slight  overlapping  in  oblique  fractures,  no  great 
trouble  attends  the  defect.  A  shortened  arm  is  not  so  objec- 
tionable as  a  shortened  thigh. 

In  compound  fractures  of  the  humerus,  the  arm  may  be 
kept  dressed  with  three  splints.  Tapes  may  be  used  instead 
of  a  bandage  to  keep  them  in  place.  The  patient  should  keep 
in  bed  for  a  week  or  two,  until  the  violence  of  the  inflamma- 
tion and  the  purulent  discharge  subside. 


Dressing  for  fracture  of  the  shaft  of  the  hu- 
merus. 3,  and  4,  are  not  seen,  and  refer  to 
two  splints  on  the  other  side  of  the  arm. 


OF  THE  SHAFT  OF  THE  HUMERUS. 


125 


FRACTURES   OF    THE   SHAFT   OF   THE    HUMERUS 
JUST  ABOVE   THE   CONDYLES. 

Falls  upon  the  hand  or  upon  the  elboAV  are  not  unfrequently 
attended  with  fracture  of  the  humerus  above  the  condyles, 
across  the  condyloid  ridges.  In  young  subjects,  the  separation 
of  the  lower  epiphysis  occurs  in  this  region,  and  presents 
nearly  all  the  characteristics  of  a  true  fracture.  Figure  39 
represents  an  injury  of  this  kind  rendered  compound  by  a  too 
tight  dressing,  which  resulted  in  sloughing,  and  a  protrusion 
of  the  broken  end  of  the  upper  fragment.  The  epiphyseal 


Separation  of  the  lower  epiphysis  of  the  hiimerns,  the  injury  rendered  compound  by 
H  Mim^ii  anil  protrusion  of  lower  end  of  upper  fragment. 

fragment  retained  its  place  in  articular  connection  with  the 
radius  and  ulna.  The  case  was  treated,  after  it  came  into  my 
hands,  by  extension,  to  enable  the  protruding  bone  to  sink 
into  place.  The  boy's  hand  was  tied  high  up  to  the  bedpost, 
so  that  the  weight  of  the  body  in  pulling  doxvnward,  exerted 
the  proper  force  to  accomplish  the  purpose. 

The  humerus  just  above  the  condyles  is  very  thin  and  pris- 
matic, expanding  laterally  at  the  expense  of  its  thickness  or 
rotundity.  This  irregular  shape  undoubtedly  weakens  the 
bone  in  that  region.  A  fall  upon  the  elbow  in  a  bent  position, 
seems  to  be  the  most  frequent  cause  of  fracture  at  all  ages. 
The  powerful  action  of  the  muscles  passing  from  the  upper 
arm  to  the  fore-arm  usually  tends  to  shortening  and  riding  of 
the  fragments.  In  most  cases  the  lower  fragment  is  drawn 
backwards  and  upwards  by  the  triceps,  producing  an  appear- 
ance similar  to  that  caused  by  dislocation  of  both  bones  of  the 
fore-arm  backwards.  The  distal  extremity  of  the  upper  frag- 


126 


FRACTURES. 


FIG.  40. 


ment  projects  in  front  of  the  arm,  making  a  prominence  just 
above  the  elbow  on  its  anterior  aspect ;  the  olecranon  projects 
backwards,  forming  a  hollow  space  in  the  arm  just  above  it, 
which  corresponds  with  the  unnatural  fullness  in  front.  The 
general  appearance  of  the  deformity  is  that  of  dislocation  ; 
and  the  restricted  motion  favors  the  same  idea- 
though  the  immobility  is  not  so  marked  as  in 
dislocation.  When  doubt  exists  in  regard  to 
the  nature  of  the  injury,  the  distinction  be- 
tween fracture  and  dislocation  can  be  drawn 
as  follows  :  an  extending  force  in  case  of  frac- 
ture, competent  to  overcome  muscular  con- 
traction, temporarily  obliterates  the  deformity, 
but,  as  soon  as  the  force  is  relaxed,  the  displace- 
ment reappears  ;  in  case  of  dislocation,  it  re- 
quires great  force  to  restore  the  parts  to  posi- 
tion, and  once  in  place  they  will  stay  there. 

When  the  broken  surfaces  are  brought  in 
contact  by  extension  and  manipulation,  and 
slight  motion  is  imparted  to  the  fragments,  dis- 
tinct crepitus  is  elicited.  It  will  also  be  found, 
in  the  event  of  fracture,  that  the  coudyles. 
which  can  always  be  felt  beneath  the  integu- 
ments, follow  the  radius  and  ulna  in  any  motion  imparted  to 
the  arm ;  and  such  movements  are  not  in  consonance  with  the 
lower  end  of  the  long  fragment.  In  dislocation,  the  condyles 
continue  as  part  of  the  hurnerus,  and  the  olecranon  is  displaced 
backwards,  forming  a  distinct  prominence  by  itself,  and  the 
condyloid  eminences  are  distinct  from  it.  The  distance  from 
the  acromion  process  to  the  internal  condyle  is  less  in  the  event 
of  fracture  than  in  dislocation. 

TREATMENT. — The  fracture  being  near  the  joint  it  is  not 
easy  to  retain  the  fragments  steadily  in  place.  Reduction  is 
to  be  effected,  as  already  intimated,  by  grasping  the  arm  with 
one  hand,  and  the  fore-arm  with  the  other,  making  sufficient 
extension  'and  counter-extension  to  overcome  the  muscular 
contraction.  In  this  way  the  fragments  may  be  brought  into 
apposition.  To  keep  them  there  the  elbow  should,  with 
proper  splints,  and  other  dressings,  be  fixed  at  a  right  angle 
A  jointed  wooden  splint  may  be  used  if  at  hand  or  readilv 


Double  fracture  of 
the  humerua. 


T11K    MIAI-T    <»F    THL    III  .Y 


127 


attainable.  If  lite  fracture  l>c  just  above  the  condyles.  the  tore- 
arm  should  be  firmly  Hexed  against  the  upper-ami  ami  held  there 
with  strips  of  rubber  adhesive  plastcis,  as  dt  pieted  in  the  cut 
below.  The  fleshy  part  of  the  fore-arm  crowds  the  fiagments 
into  place,  and  holds  them  in  conjunction,  the  strongly  flexed 
limb  acting  as  a  splint  to  the  broken  bumerus.  In  fact,  there  is 
no  other  way  to  keep  the  ends  of  the  fragments  in  apposition. 
All  jointed  splints  are  a  fraud — they  will  not  accomplish  what  is 
needed.  There  is  no  danger  of  anchylosis  at  the  elbow  while 
the  fragments  are  uniting,  and  there  is  no  fear  of  false-joint 
through  excess  of  mobility. 


Special  dressing  for  fracture  of  humerus  above  condyles. 

The  pressure  of  the  lower  end  of  the  upper  fragment  upon 
the  brachial  artery,  or  the  median  nerve,  may  operate  unfavor- 
ably upon  the  nutrition  and  functions  of  the  forearm  and  hand. 
Several  cases  of  alleged  malpractice  have  been  tried  in  differ- 
ent parts  of  the  country,  which  grew  out  of  the  enfeebled  con- 
dition of  the  parts  below  the  fracture.  It  is  worthy  of  remark, 
that  distinguished  .-urgeons,  while  giving  testimony  in  these 


128 


FRACTURES. 


FIG.  41. 


litigations,  have  differed  widely  in  regard  to  the  cause  of 
paralysis  in  the  fingers,  sloughing,  etc.  Some  have  declared 
that  the  defects  were  owing  to  injuries  done  to  the  artery  and 
nerve  by  the  broken  end  of  the  bone— condi- 
tions which  no  surgeon  could  always  avoid  ; 
and  others  were  of  the  opinion  that  tight 
bandaging,  compresses,  and  a  lack  of  adjust- 
ment of  the  fragments,  were  the  tenses  of  the 
difficulty.  It  is  highly  probable  that  in  rare 
instances  the  trouble  has  been  in  the  injury  in- 
flicted by  the  fragments,  but  in  cases  coining 
under  my  observation  the  defect  has  depended 
upon  lack  of  proper  reduction  of  the  frag- 
ments, tight  bandaging,  and  the  injudicious 
use  of  splints  and  compresses. 

If  the  fracture  be  oblique,  and  the  sharp 
edge  of  the  upper  fragment  project  forward, 
as  it  is  always  inclined  to  do,  the  brachial  artrrv 
and  median  nerve  are  about  sure  to  be  pressed 
out  of  place  and  irritated.  However,  if  the 
reduction  is  perfect,  aud  the  dressing  retains 
the  fragments  in  place,  the  edges  of  the  broken  bone  are  cov- 
ered by  one  another.  Even  if  the  apposition  be  made  perfect 
at  the  time  of  dressing,  a  fresh  displacement  may  take  place 
in  a  few  hours.  Fracture  just  above  the  condyles  must  not 
only  be  well  dressed  in  the  first  instance,  but  it  must  be  care- 
fully watched,  and  redressed  as  often  as  there  is  a  suspicion 
that  everything  is  not  going  right. 


Deformity  ;il'tcr  frac- 
ture of  humeriis 
through  its  lower 
third. 


FRACTURES    OF     THE    CONDYLES     OF    THE 
HUMERUS. 


The  condyles  of  the  humerus  are  often  fractured.  They  are 
much  exposed  to  direct  violence,  and  may  be  broken  by  indi- 
rect forces.  The  simplest  form  of  such  injuries  is  a  separation 
of  the  tip  of  the  inner  condyle  (epitrochled)t  for  the  lesion  does 
not  involve  the  articulation.  It  may  be  occasioned  by  muscu- 
lar action,  though  more  commonly  by  direct  falls  upon  the 
inner  side  of  the  elbow.  The  symptoms  of  this  fracture  are 
very  evident,  for  the  separated  portion  of  bone  can  be  easily 


OF    THE    CoXDYLES    OF  THE    IIuMKHUS.  129 

moved,  and  crepitus  is  elicited  by  the  motion.     The  swelling 
may  alter  the  appearance   of  the  articulation,  yet  a  close  ex- 
amination shows  that  the  joint  is  unimpaired,  and  no  marked 
displacement  exists.     The  capsnlar  liga-nent  and 
liii'ameutous  structures  adhering  to  the  frajrment, 

•c1  *  O 

keep  it  from  leaving  its  position.  The  muscles 
arising  from  the  epitrochlea  may  tilt  the  piece  a 
little  inwards,  yet  not  sufficiently  to  require  any 
special  appliance  to  oppose  the  tendency.  Very 

raetureofthe   little  treatment  is  required    to   secure   a   fortunate 
epitrochlea. 

result.  If  the  arm  be  carried  in  a  sling  for  sup- 
port, and  to  maintain  semitlexion  of  the  limb,  a  good  recovery 
will  be  made.  The  accident  occurs  mostly  in  children,  in 
whom  the  epitrochlea  is  connected  only  by  cartilaginous 
material,  the  tip  of  bone  being  an  epiphysis.  Cases  are  re- 
ported in  which  the  accident  has  happened  to  adults,  and  in 
whom  the  detached  fragment  has  been  drawn  downwards  an 
inch  or  more  by  the  powerful  muscles  arising  from  it. 

Fractures   through    the   articular   surfaces    are    of   a  more 
serious   character.     They  may  effect  the  inner  or  the  outer 
extending  from  that  part  of  the  bone  which  meets 
the  ulna  or  radius,  and  continue  obliquely  upwards 
and  inwards,  or  upwards  and  outwards  through  the 
condyloid  ridge,  detaching  a  piece  of  bone  some- 
what as  represented  in  the  accompanying  diagrams. 
In  instances  more  or  less  rare,  the  two  condyles  are 
split   apart,  the   line   of  fracture   dividing   so   as  to 
terminate  in   both   condyloid  ridges.     This  would 
thehumeius.  constitute  a  comminuted  and  complicated  fracture, 
allowing  the  radius  and  ulna  to  be  drawn  up  be- 
IG"  twTeen  the  fragments,  the  displacement  being  in 

part  a  dislocation.  In  such  a  case  the  distance 
between  the  two  condyles  would  be  too  great, 
and  the  arm  would  have  the  appearance  of  a  frac- 
ture of  the  humerus  just  above  the  joint,  or  a. 

Fracture  of  both     -..   ,  .  ,,     ,          ,, 

eon.iyies  of  the  dislocation  of  the  elbow. 

humerus.  T        „  ..  11-  -11- 

Iii  fractures  through  the  internal  condyle,  in- 
volving the  articular  surfaces,  the  line  of  separation  extends 
from  the  middle  of  the  trochlea,  or  concave  articular  surface 
which  receives  the  ulna,  through  the  fosste  or  depressions 
which  receive  the  two  upper  processes  of  the  ulna,  and  termi 


130 

nates  just  above  the  epitrochlea.     This  fracture  is  generally 

caused  by  direct  violence,  the  force  of  the  blow  in  falls  being 

received  directly  upon  the  condyle.     It  is  an   injury  confined 

almost  exclusively  to  childhood,  and  is  not  as  com 

mon  as  fracture  of  the  external  condyle. 

The  displacement  of  the  detached  fragment  is 
not  great  when  the  arm  is  seniiflexed  and  in  an 
easy  position.  The  separated  condyle  can  not  be 
drawn  downwards,  for  the  ulna  prevents  such  a 
displacement;  the  muscles  arising  from  it  will  not 
dnviemof c  the  permit  of  its  being  pushed  or  drawn  upwards  :  and 

humerus.  \        ,. 

the  ligaments  are  opposed  to  other  malpositions. 
However,  the  fragment  can  be  moved  when  grasped  with  the 
fingers,  and  made  to  follow  the  ulna  in  flexing  and  extending 
the  arm.  These  movements  are  almost  certain  to  produce 
crepitation.  The  distance  between  the  condyles  is  generally 
increased  a  little,  and  there  is  a  peculiar  deformity  noticed 
which  is  partly  produced  by  the  swelling,  and  partly  by  a  twist 
in  the  arm.  When  the  limb  is  grasped  above  and  below  the 
elbow,  greater  lateral  motion  can  be  imparted  to  the  joint  than 
could  be  if  no  fracture  existed.  This  is  a  valuable  diagnostic 
mano3uvre  in  ascertaining  a  fracture  of  either  condyle.  These 
deflections  do  not  determine  which  condyle  is  broken,  but 
with  a  finger  on  each,  while  lateral  movements  are  imparted 
to  the  joint,  the  point  can  be  determined. 

TREATMENT. — Anchylosis,  partial  or  complete,  is  the  danger 
to  be  apprehended  while  treating  fractures  of  either  condyle. 
As  has  been  stated,  the  displacement  can  not  be  great,  there- 
fore hard  splints,  compresses,  and  tight  bandages  are  not  re- 
quired. However,  few  patients  are  satisfied  unless  the  broken 
bone  is  "  set,"  and  the  injured  part  dressed  with  splints  and 
bandages.  To  satisfy  this  popular  demand  is  quite  desirable 
when  it  can  be  done  without  detriment  to  the  case.  In  hos- 
pitals, where  patients  are  under  the  control  of  rigid  profes- 
sional directions,  it  may  do  to  keep  the  arm  resting  on  a  pil- 
low, without  any  dressing  or  treatment,  except  topical  reme- 
dies to  keep  down  inflammation.  In  private  practice  such  a 
course  would  be  severely  criticized ;  and  unless  the  medical 
attendant  had  a  firm  hold  on  the  patient's  confidence,  he 
would  be  in  danger  of  being  dismissed  for  pursuing  such  a 


OF    THE    CONDYLES    OF  THE    IIUMEKUS. 


131 


FIG.  46. 


course.  Fortunately  for  those  who  have  to  conform  to  popu- 
lar prejudice,  fractures  of  the  condyles  cau  be  dressed  with 
pliable  splints  and  a  bandage.  A  piece  of  pasteboard  twelve 
inches  long  and  six  inches  wide,  should  have  two  inci- 
sions made  in  each  side  to  within  an  inch  of  each  other,  as 

indicated  in  the  diagram.  This 
may  then  be  wetted,  lapped  and 
bent,  so  it  will  cover  the  flexed 
elbow,  as  seen  in  Figure  46. 
After  the  arm  is  manipulated, 
to  overcome  the  displacement  if 
there  be  any,  and  the  limb  is 
flexed  to  nearly  a  right  angle,  the 
pasteboard  splint  is  applied,  and 
a  bandage  reaching  from  the 
ringers  to  near  the  shoulder,  is 
snugly  made  to  envelope  the 
limb.  Great  swellingusually  at- 
tends fracture  of  the  condyles, 
therefore  some  allowance  should 
be  made  for  that  state  if  the  arm 
be  dressed  before  the  swelling 

O 

has  reached  its  height.  Once 
dressed  in  the  way  indicated, 
the  arm  may  be  carried  in  a  lono1 

«/ 


\ 


Quadrangular  piece  of  pastfhonrd  rut  into    Olino.    Ipf    flmvn     frnm 
at  the  sides  to  make  it  conform  to  ttw    81in£>    iet    c 

Ke°ann?01'  *  A  gutta  percha  splint  moulded 

to  the  flexed  arm  answers  a  good  purpose.  Sole  leather  cut, 
wet,  and  moulded,  as  indicated  for  the  pasteboard  splint,  is 
perhaps  as  good  material  as  can  be  employed.  Angular 
wooden  and  metal  splints  are  not  desirable,  on  account  of  their 
unyielding  nature.  I  have  used  an  angular  woven  wire  splint 
with  much  satisfaction,  though  it  has  its  objections. 

The  arm  should  be  redressed  every  two  or  three  days,  and 
oftener  if  great  pain  and  swelling  seem  to  demand  it.  At  the 
end  of  two  weeks  the  elbow  should  be  subjected  daily  to  gentle 
passive  motion.  In  three  weeks  from  the  accident  the  div- 
ing maybe  wholly  removed,  and  more  forcible  passive  motion 
imparted  several  times  a  day.  If  the  limb  be  left  to  itself  the 
joint  is  almost  certain  to  become  anchylosed,  therefore  it  will 
not  do  to  trust  so  important  a  proceeding  to  the  patient. 


132  FKACTURKS. 

The  operation  of  forcibly  flexing  and  extending  the  limb  is 
attended  with  considerable  pain  ;  and  the  patient  in  attempt- 
ing to  follow  directions  is  liable  to  be  deceived  as  to  the 
amount  of  motion  imparted.  Movements  of  the  shoulder 
lead  to  the  conclusion  that  the  motion  is  in  the  elbow.  When 
the  arm  is  forcibly  flexed  or  extended,  it  should  be  held  to  the 
maximum  of  those  states  for  several  minutes  in  order  that  the 
pressure  imparted  to  the  callus  or  excess  of  reparative  material 
may  stimulate  absorption. 

Voluntary  motion,  on  account  of  the  stiffness  of  the  muscles, 
is  of  little  value.  In  forced  motion  the  joint  seems  to  lock, 
as  a  hinge  into  which  a  nail  has  accidently  slipped,  stopping 
the  normal  sweep  of  flexion.  This  impediment  arises  from 
the  amount  of  uniting  callus  in  the  articulation,  which  inter- 
feres with  the  play  of  the  hinge. 

Passive  motion  should  be  kept  up  for  a  year,  if  sufficient 
range  of  motion  be  not  obtained  before  that  time.  The 
patient  should  be  directed  to  voluntarily  put  his  fingers  to  his 
cravat,  chin,  mouth,  and  forehead  every  day.  He  can  thus 
determine  whether  he  gains  in  the  extent  of  motion.  I  have, 
in  several  instances,  taken  an  arm  that  was  quite  immovable 
when  the  dressings  were  removed,  and  restored  it  to  perfect 
action  in  the  course  of  a  few  months.  I  may  add  that  I  have 
never  failed  to  establish  a  satisfactory  range  of  motion  in  the 
elbow  in  cases  of  threatened  or  impending  anchylosis  follow- 
ing fracture  of  a  condyle.  There  is  scarcely  a  fracture  of  any 
bone  which  is  followed  with  so  many  unsatisfactory  results  as 
a  broken  condyle  of  the  humerus.  Litigations  are  numerous 
in  which  attempts  are  made  to  recover  damages  from  the  sur- 
geon who  is  unfortunate  enough  to  be  afflicted  with  unsatis- 
factory results.  Some  of  our  most  experienced  surgeons  have 
refused  to  treat  a  broken  condyle  until  the  patient  and  the 
patient's  friends  are  informed  that  the  case  would  not'be  un- 
dertaken unless  assurance  be  given  that  no  litigation  is  to  be 
commenced,  or  damages  claimed  in  the  event  af  anchylosis 
or  other  serious  defect  in  the  joint. 


OF  THE  EXTERNAL  CONDYLE.  133 

FRACTURE   OF   THE   EXTERNAL   CONDYLE. 

The  external  condyle  is  broken  more  frequently  than  the 
internal,  especially  in  adults.  Children  are  extremely  liable 
to  fracture  of  either  coudyle,  though  the  inner  oftenest  suffers. 
The  external  condj'le  is  frequently  broken  by  direct  violence, 
as  by  a  blow  or  fall;  yet  it  may  become  disjoined  by  indirect 
violence,  the  hand  receiving  the  shock  of  a  fall,  the  force  being- 
conveyed  from  the  hand  through  the  radius  to  the  humerus. 
Although  authors  have  hitherto  neglected  to  speak  of  the 
fracture  as  occurring  from  indirect  violence,  I  have  met  with 
several  examples  of  the  lesion,  in  which  the  evidence  was  that 
no  violence  had  been  received  except  upon  the  open  hand 
thrown  out  to  break  the  fall.  In  September,  1868,  I  stood 
watching  the  work  of  some  paperers,  when  one  of  the  work- 
men, John  Fordice,  who  stood  on  the  head  of  a  barrel,  lost 
his  poise,  reeled,  and  fell  to  the  floor.  He  broke  the  force  of 
the  fall  with  his  outstretched  hand,  but  received  an  injury  of 
the  elbow  that  gave  an  audible  snap.  Being  present  at  the 
time  of  the  accident,  I  had  an  opportunity  to  determine  the 
nature  of  the  lesion  before  swelling  set  in.  The  external  con- 
dyle  could  be  easily  moved  with  the  thumb  and  finger,  and 
crepitus  was  distinctly  produced  by  the  motions  imparted. 
The  fragment  was  forced  upwards,  and  the  arm  seemed  de- 
flected to  the  radial  side,  as  well  as  inclined  to  remain  in  a 
position  of  partial  flexion.  The  elbow  gained  in  lateral  mo- 
bility, and  appeared  wider  between  the  condyles.  In  a  few 
minutes  swelling  came  on  and  obscured  some  of  the  signs 
that  were  marked  at  first.  Thp.  fragment  then  was  not  so 
easily  moved  on  account  of  the  effusions  in  and  about  the 
joint,  and  the  crepitus  was  not  so  plain.  If  I  had  not  seen 
the  man  strike  on  his  hand  while  falling,  or  had  not  examined 
the  case  for  an  hour  after  the  injury,  I  might  have  suspected 
that  some  of  the  swelling  and  discoloration  which  came  on  at 
the  seat  of  injury,  was  caused  by  the  elbow  striking  heavily 
against  some  hard  substance,  and  that  the  fracture  may  have 
been  caused  by  direct  violence.  Persons  who  sustain  frac- 
tures by  falls  are  often  confused,  and  not  positive  whether  the 
elbow  hit  something  heavily,  or  the  force  was  received  on  the 
palm  of  the  hand.  Dislocations  of  the  head  of  the  radius 


134  FRACTURES. 

; 

frequently  occur  from  a  fall  received  upon  the  hand.  In  one 
case  reported  by  Hamilton,  the  dislocation  occurred  backwards 
in  conjunction  with  fracture  of  the  outer  condyle.  But  in 
that  case  the  patient  was  confident  he  struck  the  ground  with 
the  back  of  his  elbow.  It  is  not  easy  to  conjecture  how  this 
double  injury  could  arise  from  a  single  force  applied  all  at 
once,  to  say  nothing  of  the  backward  dislocation  of  the  head 
of  the  radius. 

TREATMENT. — The  displacement  being  slight  in  almost  every 
instance,  there  is  no  reduction  to  be  accomplished.  The  arm 
should  be  dressed  in  the  semiflexed  position,  and  the  same 
shaped  pasteboard  splint  employed,  as  was  recommended  for 
fracture  of  the  internal  condyle.  The  passive  motion  should 
be  commenced  by  the  fifteenth  day,  and  kept  up  daily  for  a 
week  or  two  longer  before  the  dressing  is  laid  aside.  If  the 
muscles  and  soft  tissues  be  much  stiffened,  and  there  be  evi- 
dence of  impending  anchylosis,  the  arm  should  be  forcibly 
flexed  and  extended  several  times  a  day  until  the  functions  of 
the  articulation  are  fully  restored.  The  services  of  some  friend 
or  strong  member  of  the  family  should  be  secured  to  regularly 
perform  this  important  part  of  the  treatment,  for  there  exists 
the  same  danger  of  bony  anchylosis  as  in  the  repair  of  the 
other  condyle.  The  arm  should  also  be  exercised  in  the  mo- 
tions of  pronation  and  supination.  In  the  process  of  repara- 
tion osseous  material  not  only  encroaches  upon  the  fossae  of 
the  humerus,  but  makes  connections  with  the  head  of  the 
radius,  preventing  the  normal  rotation  of  the  fore-arm. 

In  rare  instances  the  detached  condyle  fails  to  consolidate 
with  the  rest  of  the  bone.  Such  a  state  does  not  impair  the 
use  of  the  limb  to  a  degree  that  warrants  the  usual  surgical 
interference  devised  to  overcome  false-joint  or  non-union. 

In  tl;e  event  of  anchylosis  there  may  be  exceptional  cases 
in  which,  while  the  patient  is  under  profound  anesthesia, 
attempts  to  break  up  the  osseous  connections  might  be  justi- 
fiable. In  October,  1867,  Thomas  Anson,  of  Indiana,  came  to- 
me with  anchylosis  of  the  elbow  following  fracture  of  the  ex- 
ternal condyle.  The  arm  was  broken  ten  weeks  previously, 
and  had  been  treated  in  the  usual  way  by  the  family  physician. 
As  near  as  I  could  learn,  no  particular  directions  had  been 
given  about  passive  motion  to  obviate  anchylosis,  but  at  thx- 


OF  THE  EXTERNAL  CONDYLE.  135 

end  of  four  weeks,  when  the  dressings  were  removed,  the  arm 
was  allowed  to  remain  in  the  same  semiflexed  position  it  had 
been  made  to  assume  during  the  treatment.  I  put  the  patient 
under  the  influence  of  chloroform,  and  broke  the  osseous 
bridges  that  joined  the  head  of  the  radius  to  the  consolidated 
external  condyle.  No  great  amount  of  inflammation  followed 
the  disjunction.  Anodyne  and  evaporating  lotions  were  kept, 
on  the  joint  for  five  or  six  days,  and  not  much  motion  per- 
mitted, though  no  splints  or  dressings  were  used  to  overcome 
mobility.  Finding  that  no  severe  inflammation  was  likely  to 
arise,  the  joint  was  subjected  to  almost  hourly  exercises  in 
flexion  and  extension.  The  patient  went  home  on  the  tenth 
day  after  the  operation,  with  directions  to  keep  up  the  passive 
motion  for  weeks,  and  months  if  necessary.  In  a  letter  writ- 
ten six  weeks  after  he  left  for  home,  he  wrote  that  he  could 
flex  and  extend  his  arm  voluntarily,  to  a  degree  sufficient  for 
all  practical  purposes. 

Anchylosis  of  long  standing  should  not  be  treated  in  this 
way,  for  the  limb  is  not  useless  though  the  elbow  be  stiff,  and 
attempts  to  break  up  the  articular  adhesions  and  connections 
might  result  in  no  substantial  advantage.  It  is  only  while 
anchylosis  is  recent  that  a  forcible  disruption  is  justifiable. 
A  successful  attempt  to  sunder  the  adventitious  structures  has 
been  made  six  or  eight  months  after  the  reception  of  the 
original  injury,  and  other  efforts  have  failed  at  the  expiration 
of  three  months. 

Injuries  of  a  crushing  character  inflicted  upon  the  elbow, 
bruising  the  flesh  and  breaking  the  osseous  structures  of  the 
articulation,  are  sometimes  sufficiently  grave  to  demand  am- 
putation. However,  unless  the  brachial  artery  and  median 
nerve  are  known  to  be  lacerated,  it  is  commonly  prudent  to 
wait  a  few  days  to  ascertain  what  may  then  be  the  indications. 
Tli ere  is  generally  no  pressing  necessity  for  haste  after  such 
injuries,  though  every  sign  of  vitality  lias  departed  from  the 
extremity,  and  gangrene  is  apparent. 

If  there  be  feeble  pulsation  at  the  wrist,  and  partial  sensa- 
tion in  the  hand,  there  is  a  possibility,  if  not  a  probability,  of 
saving  the  limb.  At  any  rate,  a  primary  amputation,  as  it  is 
called,  should  not  be  performed  unless  the  limb,  after  reaction 
has  taken  place  in  the  rest  of  the  body,  remains  cold  and  ca- 
daverous— pulseless  and  senseless.  If  sufficient  vitality  remain 


130  FRACTURES. 

to  warrant  an  attempt  to  save  the  arm,  a  few  days  will  disclose 
the  fact  whether  the  limb  must  be  sacrificed  to  save  life,  and 
amputation  can  then  be  performed  with  not  much  greater  risk 
than  would  nave  been  incurred  just  after  the  accident. 

In  compound  and  comminuted  fracture  of  the  elbow,  the 
finger  may  be  used  to  explore  the  joint,  to  ascertain  if  any 
loose  pieces  of  bone  need  removing.  Small  fragments  com- 
pletely disengaged,  or  cut  off  from  nutritious  supplies,  are 
about  sure  to  act  as  foreign  bodies  in  the  joint;  and  may  do 
as  much  mischief  as  pieces  of  wood,  cloth,  or  common  gravel 
in  their  position.  All  such  pieces  of  isolated  bone  should  be 
removed,  and  the  limb  placed  on  a  pillow,  in  an  easy  attitude, 
for  several  days.  The  parts  implicated  in  the  injury  should 
be  kept  wet  with  water,  and  lightly  covered.  The  fcetor  may 
be  corrected  to  some  extent  by  the  use  of  dilute  carbolic  acid. 
As  soon  as  it  becomes  known  that  the  limb  can  be  saved, 
though  with  no  hope  of  motion  in  the  joint,  the  arm  should 
take  the  position  of  semiflexion,  as  the  member, when  anchy- 
losed,  is  the  most  useful  in  that  attitude.  Many  an  arm,  con- 
demned to  amputation  by  surgical  attendants,  has  been  saved 
as  a  valuable  limb,  by  the  stubborn  refusal  of  the  patient  to 
submit  to  what  was  professionally  decreed.  In  one  case,  in 
which  the  joint  was  so  opened  that  the  finger  could  be  passed 
through  and  feel  the  artery  pulsating  in  front,  Sir  Astley 
Cooper  proposed  amputation,  but  the  patient  refused  to  sub- 
mit to  it,  and  his  arm  was  saved  and  became  useful. 

A  disposition  to  amputate  after  the  reception  of  severe 
injuries  is  the  peculiarity  of  those  surgeons  who  Lave  held 
commissions  in  the  volunteer  army.  The  inclination  to  lop 
off  a  lacerated  limb  springs  from  a  desire  to  execute  a  nota- 
ble operation,  which  may  go  to  sustain  a  reputation  for  sur- 
gical ability.  However,  an  old  army  surgeon  is  apt  to  be  as 
conservative  as  the  civil  practitioner. 

If  a  limb  is  to  be  a  source  of  danger  to  life  through  pro- 
longed suppuration,  or  from  tetanic  complications,  it  is  well 
to  amputate  early;  yet  tetanus  may  generally  be  averted  by 
placing  injured  parts  in  easy  attitudes;  and  a  perilous  suppu- 
ration can  not  be  determined  for  weeks,  or  perhaps  months. 
Amputation  after  fractures  is  to  be  avoided  if  possible. 


CHAPTER    XXI. 
FRACTURE  OF    THE   ULNA. 


The  ulna,  the  companion  of  the  radius  in  the  skeleton  of 
the  fore-arm,  does  not  constitute  an  important  part  of  the 
wrist  joint,  but  enters  more  largely  than  its  fellow  into  the 
articulation  of  the  elbow.  The  bone  terminates  at  its  upper 
extremity,  in  a  prominent  process — the  olecranon — which  is  a 
lever  for  the  action  of  the  triceps.  This  process,  behind  the 

FIG.  47. 


Shows  fracture  of  the  olecranon  and  coronoid  processes. 

articulation,  is  thinly  covered,  and  exposed  to  blows  of  suffi- 
cient severity  to  cause  fracture.  If  the  fore-arm  be  suddenly 
and  forcibly  extended,  the  olecranon,  either  by  the  action  of 
the  triceps  or  the  violent  contact  of  the  humerus  in  extreme 
extension,  is  liable  to  be  broken  oft'  from  the  rest  of  the  bone. 
The  summit  or  extreme  tip  of  the  process  may  be  detached 
in  extremely  rare  cases,  though  the  fracture  usually  separates 
the  greater  part  of  the  olecranon.  In  falls  directly  upon  the 
part,  the  greater  portion  of  the  process  is  likely  to  be  broken 
off".  The  line  of  separation  is  commonly  transverse  ;  and  the 
displacement  upwards  in  the  direction  of  the  triceps,  renders 
the  nature  of  the  accident  quite  easy  to  understand.  In  some 
instances,  where  the  ligamentous  structures  are  untorn,  and 
the  arm  has  not  been  flexed,  the  displacement  is  scarcely  per- 
ceptible. In  most  cases  the  process  is  retracted  to  so  great  an 
extent  by  the  triceps,  that  every  connecting  medium  must  be 
torn  through,  the  fragment  being  entirely  under  the  control 
of  the  muscle.  Flexing  the  arm  puts  the  triceps  on  the 

(137) 


138  FRACTURES. 

stretch,  and  necessarily  widens  the  breach  between  the  frag- 
rnents.  Displaced  as  the  process  usually  is  after  fracture,  it 
can  be  distinctly  felt  an  inch  or  so  above  its  ordinary  location, 
and  is  easily  movable  from  side  to  side.  Power  of  voluntary 
extension  is  almost  entirely  lost  after  fracture  of  the  olecra- 
non,  and  pain  is  aggravated  by  movements  of  the  limb. 
Swelling  quickly  follows  the  injury,  and  tends  to  obscure  the 
diagnosis  if  the  patient  be  not  examined  for  several  hours 
after  the  accident.  Crepitus  can  not  be  elicited  unless  the  arm 
be  extended,  and  the  triceps  pressed  downwards,  so  that  the 
broken  surfaces  may  be  brought  in  contact. 

In  doubtful  cases,  when  there  is  no  apparent  displacement, 
the  finger  placed  upon  the  olecranon  while  the  arm  is  flexed, 
will  discover  the  line  of  separation  which  is  always  more  or 
less  marked  by  a  lack  of  perfect  apposition.  If  the  arm  be 
put  into  extreme  flexion,  the  fragments  are  forced  apart  and 
a  palpable  depression  is  felt  between  them. 

TREATMENT. — It  is  plainly  evident  that  fracture  of  the  ole- 
cranon is  to  be  treated  with  the  arm  in  a  state  of  extreme  ex 

FIG.  48. 


Splint  and  dressingfor  fracture  of  the  olecranon  pro< 

tension  ;  and  a  long- splint  reaching  from  near  the  shoulder  to 
the  hand,  and  bound  to  the  front  aspect  of  the  limb,  will  keep 
the  arm  from  being  flexed.  A  roller  bandage  begun  at  the 
fingers  should  extend  to  the  elbow  ;  then  another  started  near 
the  shoulder  is  made  in  its  turns  to  envelope  the  arm  down  to 
and  including  the  elbow.  The  first  prevents  undue  congestion 
and  swelling,  and  the  other  forces  the  triceps  downwards  s<> 
tjiat  the  detached  olecranon  may  come  in  contact  witli  the 
rest  of  the  bone.  The  long  straight  splint  is  now  placed  on 
the  front  of  the  arm  and  fastened  there  by  the  turns  of  an- 
other roller.  This  dressing  holds  the  limb  in  a  st might  posi- 
tion, which  is  somewhat  awkward,  but  it  is  the  onlv  wav  the 


OF  THE  ULNA.  139 

broken  surfaces  can  be  brought  into  apposition  and  held  there 
securely.  As  there  is  danger  of  severe  inflammation  in  the 
joint,  anodyne  and  evaporating  lotions  should  be  applied  to 
the  elbow  for  several  days.  The  dressing  may  be  taken  off 
and  re-applied  occasionally  during  the  healing  process,  though 
the  joint  should  not  be  fully  flexed  for  five  or  six  weeks,  lest 
the  fragments  be  forced  apart.  At  the  expiration  of  that 
time,  the  state  of  the  parts  involved  in  the  injury  should  be 
carefully  observed,  to  ascertain  whether  the  union  of  the  frag- 
ments be  osseous.  If  the  consolidation  be  perfect,  whatever 
of  stiffness  and  anchylosis  exist,  should  be  overcome  by  passive 
motion.  The  arm  should  not  be  fully  flexed  at  first,  but  there 
ought  to  be  a  gradual  restoration  of  the  functions  of  the 
joint.  If  the  union  be  fibrous,  which  by  some  surgeons  is 
thought  to  be  the  normal  state  after  fracture  of  the  olecranon, 
the  connecting  bands  will  be  so  short  that  the  use  of  the  limb 
is  but  slightly  impaired.  Extension  can  be  performed  even  if 
the  union  be  fibrous  or  ligameutous.  In  the  event  of  false- 
joint,  especially  if  the  connecting  bands  be  short,  it  is  not  best 
to  attempt  the  establishment  of  bony  union  by  any  of  the 
means  usually  employed  for  such  purposes. 

The  only  objections  raised  against  dressing  the  arm  ia  the 
extended  position  is,  that  if  anchylosis  does  take  place,  the  limb 
is  not  in  a  good  attitude  for  service.  It  is  justly  claimed  that 
if  the  joint  is  to  be  permanently  stiff,  the  semiflexed  position 
is  far  preferable  to  a  straight  attitude.  However,  it  is  found 
in  practice  that  the  cases  in  which  complete  anchylosis  results, 
are  extremely  uncommon.  If  the  articulation  be  severely  in- 
jured at  the  time  the  fracture  occurs,  so  that  anchylosis  seems 
inevitable,  it  might  be  wise  to  dress  the  arm  in  a  position 
which  would  be  most  useful,  for  if  the  elbow  be  anchylosed 
it  would  make  little  difference  whether  the  olecranou  was 
consolidated  or  not. 

It  is  recommended  by  Hamilton  that  moderate  flexion  and 
extension  be  performed  every  day,  while  the  dressing  is  oft', 
the  finger  pressing  downwards  upon  the  olecranon,  to  obviate 
anchylosis,  but  this  increases  greatly  the  risk  of  fibrous  union, 
and  opposes  in  a  slight  degree  anchylosis  which  is  very  un- 
likely to  occur. 


140  FKACTURES. 


FRACTURE  OF  THE   CORONOID   PROCESS. 

Fracture  of  the  coronoid  process  must  be  an  extremely  rare 
accident.  The  surgeons  are  few  who  have  been  positive  that 
they  have  seen  a  case.  Several  cases  have  been  reported,  but 
full  credence  can  not  be  placed  in  all  of  them.  The  accident 
is  said  to  occur  in  connection  with  dislocation  of  the  radius 
and  ulna  backwards,  and  sometimes  perhaps  without  that 
complication.  It  has  been  stated  by  surgical  writers  that  the 
action  of  the  brachialis  anticus  would  break  the  process  ;  their 
language  being  that  the  muscle  is  inserted  into  the  process, 
when  in  fact  it  is  inserted  below  or  at  the  base  of  that  promi- 
nence of  bone,  and  has  no  direct  action  upon  it.  The  occa- 
sion for  distrust  in  some  of  the  reported  cases  comes  from  the 
anatomical  error  into  which  writers  have  so  frequently  fallen. 
In  a  malpractice  suit  tried  in  the  State  of  New  York, 
one  of  the  surgical  experts  in  his  testimony  in  regard  to  dis- 
location of  the  radius  and  ulna  backwards,  stated  that  the 
brachialis  muscle  was  inserted  into  the  apex  of  the  coronoid 
process.  Mr.  Liston,  in  his  Operative  Surgery,  mentions  the 
case  of  a  boy  who  broke  the  coronoid  process  by  the  action 
of  the  brachialis  muscle  while  hanging  from  a  high  wall. 
Notwithstanding  our  great  regard  for  such  high  authority, 
it  will  be  convincing  to  any  one  referring  to  the  anatomy  of 
the  parts  involved  in  the  alleged  injury  and  considering  tin- 
action  of  the  muscle  upon  the  process  while  a  boy  was  hang- 
ing by  the  arm,  that  no  such  lesion  could  take  place.  Tho 
boy's  weight  as  he  was  suspended  by  the  hand,  would  draw 
the  coronoid  process  away  from  close  contact  with  the  hume- 
rus,  and  the  brachialis  anticus  muscle,  being  inserted  at  the 
base  of  the  process,  also  passing  over  it,  would  press  upon 
its  apex,  the  action  tending  to  retain  the  bony  prominence  in 
place,  and  not  to  detach  it,  while  the  arm  was  in  extreme  ex- 
tension. The  coronoid  process  is  not  an  epiphysis,  with  a 
cartilaginous  connection  with  the  shaft  of  the  ulna  during 
childhood;  which  is  another  circumstance  opposed  to  the 
theory  of  fracture  from  muscular  action,  though  it  is  declared 
by  nearly  all  writers  upon  the  subject,  that  children  and  not 
adults,  are  liable  to  the  accident. 


SHAFT  OF  THE  ULNA.  141 

It  is  not  denied  that  direct  violence,  as  the  passage  of  a 
wheel  over  the  part,  may  break  oft'  the  coronoid  process ;  and 
it  is  quite  certain  that  in  dislocations  of  the  ulna  backwards, 
the  point  of  bone  is  occasionally  severed  from  its  connections 
with  the  main  part  of  the  bone. 

TREATMENT. — The  dislocation  having  been  reduced,  for  the 
fracture  is  presumed  not  to  occur  except  in  conjunction  with 
that  injury,  the  arm  should  be  kept  in  a  state  of  partial  flexion 
to  prevent  a  recurrence  of  the  luxation.  The  limb  may  be 
handaged  from  the  lingers  to  a  point  above  the  elbow,  and  a 
compress  employed  to  retain  the  detached  process  in  place. 
This  dressing  c:m  be  employed  for  four  or  live  weeks,  though 
the  articulation  is  to  be  gently  exercised  daily  to  prevent  an- 
chylosis. The  difficulty  of  retaining  so  small  a  fragment 
steadily  in  position,  and  the  scanty  nutritive  materials  iinding 
their  way  to  the  process  after  its  violent  separation  from  the 
shaft,  would  be  liable  to  insure  a  ligamentous,  and  not  a  bony 
connection.  If  the  detached  process  never  obtained  a  firm 
connection  with  the  shaft  of  the  ulna,  the  osseous  material 
poured  out  to  consolidate  the  fragments,  would  constitute  a 
barrier  against  repeated  dislocations.  The  functions  of  the 
joint,  under  such  circumstances,  must  be  more  or  less  im- 
paired, for  the  elbow  is  liable  to  chronic  defects  after  even 
moderate  injuries.  It  is  vastly  more  important  to  secure  free 
motion  to  the  joint,  than  to  be  striving  for  bony  union,  which 
would  be  ntterlv  useless  in  the  event  of  anchvlosis. 


FRACTURE  OF  THE  SHAFT  OF  THE  ULNA. 

The  shaft  of  the  ulna,  when  fractured  singly,  is  always 
broken  by  direct  force.  If  the  radius  be  previously  broken, 
the  ulna  may  be  brought  under  the  influence  of  the  indirect 
force,  and  be  fractured  by  it.  When  the  hand  is  extended  in 
falls  to  save  the  head  and  trunk  from  violence,  the  radius, 
from  the  mode  of  articulation  in  the  fore-arm,  receives  the 
force  of  the  blow  and  either  breaks  just  above  the  wrist,  or 
conveys  the  shock  to  the  humerus ;  thus  the  ulna  is  preserved 
from  heavy  concussion.  The  ulna  is  subject,  then,  to  direct 
violence,  either  in  striking  against  some  hard  body,  or  in 


142  FRACTURES. 

warding  a  blow  aimed  at  the  body.  The  arm  is  raised  in  pro- 
tecting the  head,  to  an  attitude  which  presents  its  ulna  side 
toward  the  threatening  violence.  Also  in  falling  backwards, 
the  arm  is  thrown  in  advance  of  the  trunk  to  shield  it  from 
injury,  and  receives  a  violent  shock  on  its  ulnar  side.  While 
descending  stairs,  a  slip  of  the  feet  forwards  throws  the  body 
backwards,  and  the  ulnar  sides  of  the  arms  come  directly 
against  the  edge  of  a  step. 

The  situation  of  the  fracture  under  such  circumstances,  de- 
pends of  course  upon  the  part  of  the  bone  struck.  The  lower 
half  of  the  bone  is  smaller  and  weaker  than  the  upper  half, 

FIG.  49. 


Fracture  of  the  ulna  above  the  origin  of  the  pronatpr  quadratus, 
showing  the  action  of  that  muscle  upon  the  lower  fragment. 

and  should  consequently  be  most  frequently  broken,  all  other 
conditions  being  equal:  A  force  producing  fracture  of  the 
shaft  of  the  ulna,  is  very  liable  to  convert  the  lesion  into  one 
of  a  compound  nature. 

The  symptoms  of  fracture  are  usually  very  prominent.  The 
bone  being  thinly  covered,  the  displacement  is  generally  quite 
marked.  However,  in  some  instances,  especially  towards  the 
upper  extremity  of  the  bone,  the  fragments  may  be  interlocked, 
or  held  in  place  by  the  periosteum,  so  that  no  disjunction 
occurs.  In  fractures  through  the  lower  portion  of  the  bone, 
the  upper  fragment  remains  nearly  in  the  place  occupied  before 
the  fracture,  owing  to  the  firm  and  Avide  articulation  at  the 
elbow,  and  the  lower  fragment  is  drawn  towards  the  radius  by 
the  action  of  the  pronator  quadratus  muscle.  If  the  upper 
end  of  the  lower  fragment  take  any  other  position,  it  is  driven 


SHAFT  OP  THE  ULNA.  143 

there  by  the  force  that  produced  the  fracture,  and  the  muscular 
action  was  too  feeble  to  restore  it  to  the  place  it  would  take  if 
uninfluenced  by  the  paralyzing  blow.  When  the  broken  ends 
are  brought  in  contact,  in  the  manipulations  of  the  arm,  cre- 
pitus  is  distinctly  felt  and  heard.  The  power  of  rotation  is 
impaired  by  fracture  of  the  ulna,  and  in  fact  all  the  functions 
of  the  fore-arm  are  restrained  by  the  swelling,  pain,  and  loss 
of  power  attendant  upon  tke  lesion. 

In  May,  1865,  I  was  called  to  Mollie  Shannon,  a  stout  Irish 
girl,  who  fell  backward  from  a  stool  while  hanging  out 
clothes.  The  fall  brought  her  upon  a  flight  of  back  stains, 
and  she  slid  to  the  bottom,  lighting  upon  a  brick  pavement. 
I  saw  her  in  a  few  minutes  after  the  injuries  were  received. 
She  was  complaining  bitterly  of  her  arm  near  the  elbow,  and 
refused  to  allow  me  to  examine  it  as  thoroughly  as  I  desired, 
on  account  of  the  pain  which  the  slightest  manipulation 
seemed  to  produce.  I  therefore  gave  her  chloroform  until  I 
could  handle  the  limb,  and  ascertain  the  nature  and  extent  of 
the  injury.  A  contusion  about  five  inches  below  the  elbow  on 
the  ulnar  aspect  of  the  arm,  led  to  a  critical  examination  of 
the  bone  beneath.  I  found  a  fracture  of  the  ulna  at  that 
point,  though  not  much  displacement  existed.  There  was 
swelling  about  the  elbow,  which,  with  a  huge  development  of 
the  muscles,  rendered  the  nature  of  any  injury  in  that  region 
perplexingly  obscure.  The  rigidity  of  the  joint,  and  the  pe- 
culiar twist,  amounting  to  marked  distortion,  which  the  limb 
assumed,  favored  the  idea  of  dislocation  of  the  head  of  the 
radius.  To  this  conclusion  I  at  length  arrived,  though  not 
with  that  certainty  which  fully  satisfies  the  mind.  After  put- 
ting the  patient  under  profound  anaesthesia  I  succeeded  in  re- 
ducing the  dislocation,  and  then  the  arm  became  supple,  and 
the  fracture  of  the  ulna  permitted  of  the  plainest  crepitation, 
which  could  not  be  elicited  until  the  luxation  was  reduced. 
To  understand  how  both  injuries  were  produced  is  not  easy, 
unless  the  ulna  was  broken  against  the  sharp  angle  of  the 
post  at  the  head  of  the  stairs,  and  at  the  time  she  fell  from 
the  stool ;  the  dislocation  of  the  head  of  the  radius  upon  the 
anterior  aspect  of  the  condyle,  must  have  been  done  when  she 
landed  at  the  foot  of  the  stairs,  where  the  great  weight  of  her 
body  came  upon  the  injured  arm,  which,  she  said,  "  doubled 
up  under  me."  The  case  made  a  good  recovery. 


144  FRACTURES. 

TREATMENT. — It  is  not  generally  a  difficult  matter  to  reduce 
a  simple  fracture  of  the  ulna.  The  broken  ends,  whether  they 
project  in  one  direction  or  another,  or  the  upper  fragment  be 
in  position  and  the  lower  dragged  into  the  interosseous  space, 
toward  the  radius,  can  commonly  be  manipulated  into  appo- 
sition without  deviation  from  the  natural  course  of  the  bone. 
The  fragments  once  brought  into  line  and  properly  adjusted, 
two  padded  board  splints,  wider  than  the  arm,  and  reaching 
from  the  elbow  to  the  lingers,  are  to  be  bound  to  the  anterior 
and  posterior  aspects  of  the  arm,  while  the  hand  is  held  half 
way  between  pronation  and  supinatiou.  ]STo  roller  should  be 
applied  except  the  one  that  holds  the  splints  in  place.  Any 
circular  compression  is  extremely  liable  to  press  one  or  both 
fragments  into  the  interosseous  space,  where  the}'  may  unite 
to  the  radius,  destroying  the  functions  of  pronation  and  supi- 
nation.  [f  the  fracture  be  through  the  lower  third  of  the 
bone,  and  the  lower  fragment  is  quite  forcibly  drawn  toward 
the  radius,  two  long,  firm  compresses  should  be  laid  between 
the  radius  and  ulna,  beneath  the  splints.  These  tend  to  wedge 
the  bones  apart.  The  width  of  the  splints  prevents  anything 
but  lateral  compression.  As  the  bandage,  while  it  is  being 
put  on,  passes  across  fronl  one  splint  to  the  other,  the  upper 
and  lower  surfaces  of  the  arm  remain  untouched,  thus  entirely 
obviating  circular  compression.  After  the  arm  is  properly 
dressed,  it  may  -be  carried  in  a  sling.  The  redressings  need 
not  be  frequent  unless  there  arise  a  suspicion  that  all  is  not 
well.  In  the  usual  time,  which  is  about  four  or  five  week-. 
the  dressings  may  be  filially  removed.  False-joint  after  frac- 
ture of  the  shaft  of  the  ulna  is  extremely  rare.  The  callus  is 
plainly  felt  for  months,  on  account  of  the  subcutaneous  loca- 
tion of  the  bone. 


CHAPTER    XXII. 

FRACTURE  OF  THE  RADIUS,  ETC. 


The  upper  third  of  the  radius,  from  its  being  buried  deeply 
in  muscles,  is  seldom  fractured;  the  middle  third  is  not  broken 
any  more  frequently  than  the  ulna  ;  but  the  lower  third  is 
fractured  more  often  than  any  part  of  any  other  bone  in  tlie 
body. 

Fracture  of  the  neck  of  the  radius  is  admitted  by  every  ex- 
perienced surgeon  to  be  extremely  rare.  Dr.  Markoe,  of  Xrw 
York,  thought  he  met  with  a  cast-  in  which  the  signs  pointed 
inevitably  to  a  fracture  through  the  neck  of  the  radius,  but 
the  autopsy  showed  that  he  had  been  mistaken.  The  injury 
proved  to  be  a  dislocation  of  the  head  of  the  radius  forwards, 
and  a  fracture  of  the  ulna  near  the  elbow.  The  mobility  of 
the  parts  and  the  crepitus  which  seemed  to  come  from  the 
radial  side  of  the  arm,  fed  to  the  error  of  diagnosis.  Mutter's 
cabinet  in  Philadelphia,  contains  a  specimen  of  fracture 
through  the  neck  of  the  radius,  which  I  have  examined.  The 
history  of  the  case  is  unknown.  The  fracture  united  with 
considerable  deformity,  which  must  have  interfered  consider- 
ably with  the  functions  of  the  elbow. 

In  the  winter  of  1855,  Mr.  Xoyes,  of  Boston,  was  thrown 
from  a  sleigh  in  Lowell,  and  received  a  severe  injury  about 
the  elbow.  He  went  to  a  hotel,  and  requested  that  a  surgeon 
be  called  to  treat  his  arm.  The  landlord  sent  for  Dr.  Xathan 
Allen,  his  family  physician.  Upon  his  arrival,  the  doctor  ex- 
amined the  injury,  and  pronounced  it  a  sprain.  He  applied  a 
bandage  to  suppress  the  swelling,  and  ordered  wormwood  and 
rum  as  a  topical  application.  Several  professional  visits  were 
made  Mr.  Xoyes  while  he  was  at  the  hotel,  and  assurances 
were  given  that  in  a  few  days  the  patient  would  be  able  to 
resume  his  business.  After  several  weeks  Mr.  Noyes  found 
10  (145) 


146  FRACTURES. 

that  he  could  not  bend  the  elbow  except  in  a  very  moderate 
degree;  he  could  not  carry  his  fingers  to  the  chin,  even  if  the 
head  was  bent  to  meet  them.  Accordingly  he  went  to  the 
late  Dr.  John  C.  Warren,  of  Boston,  for  an  opinion  in  regard 
to  the  nature  of  the  injury  and  the  prospects  of  a  cure.  Dr. 
W.  asked  "  who  had  treated  the  arm;"  and  upon  being  told 
that  it  was  Dr.  Allen,  he  would  not  look  at  the  case,  as  Dr. 
A.  was  a  professional  brother  in  the  Massachusetts  Medical 
Society.  Mr.  N.  then  went  to  Dr.  Kimball,  of  Lowell,  a  sur- 
geon of  some  repute.  Dr.  K.  examined  the  arm,  and  called 
his  student's  attention  to  what  he  called  a  fracture  of  the  condyle. 
Mr.  X.  then  went  to  Dr.  Walter  Burnham,  of  Lowell,  also  a 
surgeon  of  large  experience,  who  pronounced  the  injury  a 
fracture  of  the  neck  of  the  radius,  which  was  ununited.  Mr. 
N.  now  supposed  that  he  had  been  maltreated  by  Dr.  Allen, 
and  sued  him  for  damages.  The  case  was  tried  at  East  Cam- 
bridge, in  Middlesex  County,  in  January,  185*3,  and  resulted 
in  a  disagreement  of  the  jury.  The  testimony  given  in  court 
was  singularly  conflicting,  coming  as  it  did  from  some  of  the 
most  accomplished  and  experienced  surgeons  in  the  State. 

It  was  also  a  matter  of  surprise  to  Mr.  Noyes  that  Dr. 
Kimball,  who  had  directed  his  student  to  observe  an  old  frac- 
ture of  the  condyle,  should  then  under  oath  declare  that 
the  arm  had  never  sustained  a  fracture.  The  real  state  of  the 
limb,  at  the  time  of  the  trial  was  as  foliows :  there  was  partial 
anchylosis  at  the  elbow,  flexion  being  greatly  impeded,  as  has 
been  stated  ;  pronation  and  supination  restricted ;  and  a  grat- 
ing could  be  produced  just  below  the  elbow  by  passive  efforts 
at  rotation  of  the  fore-arm.  There  was  no  evidence  that  the 
condyles  of  the  humerus  had  ever  been  broken.  The  ulna 
seemed  perfect  in  its  processes  and  proportions,  bearing  no 
sign  of  fracture.  The  head  of  the  radius  was  not  dislocated, 
for  it  could  be  grasped  with  the  thumb  and  finger,  and  plainly 
rotated,  and  it  could  be  held  still  while  the  hand  and  lower 
extremity  of  the  bone  were  rotated.  These  movements  elicited 
a  crepitating  sound  much  like  that  heard  in  the  motions  of  a 
false-joint.  The  evidence  of  fracture  of  the  neck  of  the  radius 
was  reached  by  a  logical  necessity,  on  the  application  of  a 
method  of  reasoning  much  resorted  to  in  the  diagnosis  of  dis- 
eases, viz.,  reasoning  by  way  of  exclusion.  That  there  had  been 
a  fracture  about  the  joint  was  quite  plain,  and  as  the  humerua 


OF  THE  RADIUS. 


147 


and  ulna  were  excluded  from  the  possibility  of  having  been 
fractured,  the  upper  extremity  of  the  radius  alone  remained 
unexcluded,  and  every  symptom  in  the  cuse  indicated  fracture 
of  the  neck  of  the  bone,  whether  the  injury  had  previously 
IHTII  met  or  not  by  surgeons  high  in  authority. 

In  fractures  of  the  head  or  neck  of  the  radius,  the  arm 
should  be  flexed  to  relax  the  biceps  which  has  its  insertion  just 
below  the  tubercle  and  tends  to  displace  the  upper  extremity 
of  the  long  fragment.  The  pasteboard  splint  recommended 
for  fracture  of  the  condyles  of  the  humerus,  would  be  excel- 
lent to  steady  and  support  the  parts  implicated  in  the  injury. 
At  the  end  of  three  or  four  weeks  motion  should  be  imparted 
to  the  joint  to  obviate  anchylosis. 

In  fractures  of  the  radius  which  very  rarely  occur  between 
the  attachment  of  the  biceps  and  the  insertion  of  the  prouator 
radii  teres,  the  fragments  are  acted  upon  by  muscles  exerting 
their  forces  in  different  directions.  The  supinator  brevis  rolls 

FIG.  50. 


Fracture  of  the  radius  between  the  insertions  of  the  supinator  hrevis  and  pronator  radii  teres. 
The  fragments  are  separated  by  the  action  of  these  muscles. 

FIG.  51. 


Arm  supinnted  to  bring  the  lower 


into  apposition  with  the  upper. 


the  short,  upper  piece  of  bone  outwards,  and  the  antagonistic 
pronator  pulls  the  lower  piece  inwards,  somewhat  as  exhibited 
in  Figure  50.  Now,  as  the  upper  fragment  is  short  and 
thickly  covered  with  muscular  tissue,  it  can  not  be  moved 
from  the  position  given  to  it  by  the  supinator  brevis  ;  but  the 


148  FRACTURES. 

lower  fragment  can  be  made  to  come  in  contact  with  the  upper 
by  the  extreme  supination  of  the  fore-arm,  as  seen  in  Figure 
51.  To  treat  such  a  fracture  successfully,  the  arm  would  have 
to  be  dressed  in  the  attitude  of  extreme  supination,  and  re- 
tained in  that  position  until  the  consolidation  of  the  fragments 
was  sufficient  to  allow  of  rotation,  and  not  endanger  the 
breaking  up  of  the  callus.  I  have  never  treated  but  one  case 
of  the  kind,  which  was  produced  by  a  pistol  bullet,  and  in 
that  I  followed  the  course  just  laid  down.  The  recovery  was 
not  rapid,  for  the  injury  was  rendered  compound  by  the  bullet 
wound.  Two  splints  made  of  thin  boards,  two  inches  and  a 
half  wide,  and  reaching  from  the  elbow  to  the  ends  of  the 
fingers,  were  bound  in  place  by  a  roller  while  the  arm  was 
supine.  The  back  of  the  hand  was  allowed  to  rest  in  a  sling, 
strict  orders  being  given  to  keep  the  thumb  directed  away 
from  the  body.  The  position  was  irksome  at  first,  but  in  a 
few  days  it  was  maintained  without  effort. 

Fracture  through  the  middle  third  of  the  radius,  below  the 
insertion  of  the  pronator  radii  teres.  is  generally  caused  by 

FIG.  52. 


Fraotnreof  the  middle  third  of  the  radius.    The  biceps  (2)  tends  to  pull  the  upper  fragment 

in  one  direction,  and  the  pronator  quadratus  (7)  the  lower  fragment  into  the 

interosseous  space. 

direct  violence,  and  happens  about  as  rarely  as  fracture  through 
the  middle  third  of  the  ulna.  The  diagnosis  is  unattended 
with  difficulty.  Eotation  developes  so  much  displacement 
that  the  ends  of  the  fragments  can  be  distinctly  felt  beneath 
the  integuments.  Crepitus  can  also  be  produced  when  the 
fragments  are  brought  in  contact  and  rubbed  against  one  an- 
other. The  inclination  of  the  broken  ends  is  to  take  a  posi- 
tion in  the  interosseous  space,  approximating  the  ulna. 

The  treatment  is  the  same  as  for  fractured  ulna  in  the  same 


OF  THE  RADIUS.  149 

region.  Two  straight  splints,  wider  than  the  arm,  to  obviate 
circular  compression,  and  padded  to  prevent  excoriation  of 
the  skin,  are  to  he  bandaged  to  the  dorsal  and  front  aspects  of 
the  fore-arm.  A  compress  placed  under  each  splint  between 
the  hones,  so  as  to  force  the  fragments  away  from  the  ulna, 
tends  to  prevent  the  reparative  material  from  soldering  one  or 
both  broken  ends  to  the  ulna,  as  represented  in  Figure  53.  If 
one  or  both  fragments  become  welded  to  the  ulna,  the  coudi- 

FIG.  53. 


Consolidation  of  fragments  of  railiu*  with  the  ulna,  preventing 
rotation  of  the  fore-arm. 

tion  is  fatal  to  rotation.  Ordinarily  it  is  not  necessary,  in 
treating  fractures  near  the  middle  of  the  radius,  to  use  splints 
extending  farther  than  from  the  elbow  to  the  hand.  These 
reach  quite  a  distance  above  and  below  the  line  of  fracture,  so 
that  no  motion  at  the  point  of  separation  can  take  place  if  the 
splints  be  efficiently  held  with  bandages.  Figure  61  represents 
the  splints  padded  and  held  in  place  with  a  couple  of  tapes 
preparatory  to  receiving  the  bandage. 

FRACTURE    THROUGH    THE    LOWER     THIRD    OF 
THE   RADIUS. 

There  is  no  part  of  the  skeleton  so  subject  to  fracture  as 
the  lower  extremity  of  the  radius.  The  lesion  occurs  from 
indirect  violence.  The  hand  in  a  fall  is  put  forth  to  arrest  the 
progress  of  the  descent,  and  to  save  the  head  and  the  trunk 
from  serious  blows  and  concussions.  These  uses  are  the  occa- 
sion of  so  many  fractures  of  the  radius  near  the  wrist.  The 
expanded  articular  extremity  of  the  bone  receives  the  carpus, 
leaving  the  ulna  free  from  the  shocks  sent  along  from  the 
hand  to  the  fore-arm.  The  lower  end  of  the  radius,  though 
quite  large,  has  a  thin  shell  of  hard  bone  upon  the  outside, 
and  an  abundance  of  cancellated  structure  within. 

Several  distinguished  surgeons  in  this  country  and  abroad, 
have  written  upon  the  nature,  appearances,  and  treatment  of 


150  FRACTURES. 

fractures  occurring  at  the  lower  extremity  of  the  radium,  and 
a  few  of  them  have  gotten  their  names  associated  with  varie- 
ties of  the  injury.  In  1814  Dr.  Abraham  Colles,  of  Dublin, 
published  an  article  in  the  Edinburgh  Medical  and  Surgical 
Journal,  upon  the  peculiarities  of  a  fracture  commonly  occur- 
ring about  an  inch  from  the  carpal  extremity  of  the  radius ; 
and  since  that  time  all  fractures  of  the  lower  portion  of  the 
radius,  except  such  as  involved  the  articular  surface  of  the 
bone,  have  been  called  "  Cones'  fracture."  In  1838,  Dr.  J. 
Rhea  Barton,  of  Philadelphia,  published  an  article  in  the 
Philadelphia  Medical  Examiner,  on  the  subject  of  fractures  of 
the  carpal  extremity  of  the  radius.  He  called  particular 
attention  to  such  fractures  as  involved  the  articular  surface  ot 
the  bone,  claiming  that  in  many  instances  the  line  of  separa- 
tion was  not  so  far  from  the  wrist-joint  as  described  by  Colles. 
Since  the  publication  of  the  article  American  surgeons  have 

FIG.  54. 


"Barton's  fracture"  of  the  lower  extremity  of  the  radius.    The  action  of  the  snpinator 
longus  and  prouator  quadratus  is  exhibited  in  the  position  of  the  fragments. 

commonly  called  the  injury,  when  the  articulation  isinvolvedT 
"  Barton's  fracture"  Both  writers  have  described  injuries  pro- 
duced by  the  same  causes,  and  presenting  the  same  peculiari- 
ties. There  is  no  difference  between  Colles'  fracture  and  Bar- 
ton's fracture,  unless  it  be  that  the  latter  name  belongs  to  such 
lesions  as  present  a  break  extending  to  the  carpal  articular 
surface.  In  the  production  of  both  fractures  the  hand  is 
thrown  out  instinctively  to  break  the  force  of  a  fall,  and  when 
the  carpus  meets  the  earth  or  the  resistance  of  anything 
stable,  the  momentum  of  the  body  causes  a  fracture  at  the 
weakest  part  of  the  bone. 

The  deformity  following  fracture  of  the  radius  near  the 
wrist  is  observable,  yet  to  an  inexperienced  person  the  nature 
of  the  difficulty  is  rather  obscure.  The  swelling  which  rapidly 


OF  THE  RADIUS. 


151 


supervenes,  masks  the  irregularities  of  the  broken  surfaces, 
ami  otherwise  conceals  the  symptoms  of  fracture.  The  ap- 
pearances of  the  parts  may  lead  to  the  suspicion  of  ladio- 
<;arpal  luxation.  If  the  hand  and  fore-arm  of  the  patient  be 
grasped  and  subjected  to  extending  and  counter-extending 
forces,  the  injured  limb  in  case  of  fracture,  will  be  made  to 
assume  its  natural  outlines  and  projections.  In  the  event  of 
radio-carpal  dislocation,  which  is  an  exceedingly  uncommon 
lesion,  the  deformities  can  not  readily  be  overcome  by  such 
force  ;  and  when  once  in  place  the  bones  will  stay  there.  The 
deformities  attendant  upon  fracture  are  easily  overcome,  but 
they  will  immediately  recur  upon  the  relaxation  of  the  re- 
ducing forces. 

The  peculiar  appearance  of  an  arm  suffering  from  fracture 
of  the  carpal  extremity  of  the  radius,  has  been  compared  to 
the  outline  of  a  silver  fork.  The  accompanying  diagram  re- 
presents it  pretty  well.  An  elevation  presents  on  the  wrist, 

FIG.  55. 


"  Silver  fork  "  appearance  of  the  hand  and  arm  after  Colles'  fracture  of  the  radius. 

extending  to  the  back  of  the  hand.  This  dorsal  prominence 
is  nearly  apposite  or  a  counterpart  to  a  deep  sulcus  or  depres- 
sion on  the  palmar  aspect  of  the  wrist.  Higher  on  the  front 
of  the  arm,  above  the  sulcus,  is  a  marked  prominence.  Besides 
these  deformities,  there  is  an  abnormal  projection  of  the  lower 
extremity  of  the  ulna,  as  if  the  carpus  was  dislocated  laterally 
to  the  radial  side.  The  muscles  going  to  the  thumb  tend  to 
pull  the  hand  away  from  the  ulna. 

In  seeking  positive  evidence  of  the  fracture  under  consider- 
ation, crepitus  becomes  important.  This  valuable  sign  can 
generally  be  elicited  by  grasping  the  hand  and  arm,  and  im- 
parting various  movements  to  the  wrist.  The  finger  pressed 
upon  the  radius  immediately  above  the  articulation,  while  the 
movements  just  spoken  <>f  are  made,  will  discover  the' sharp 
or  rough  edges  of  the  !)rok.-n  ends  of  the  fragments,  or  such 


152 


FRACTURES. 


irregularities  in  the  bone  within  an  inch  or  two  of  the  joint, 
as  will  be  quite  conclusive  as  to  the  nature  of  the  injury,  the 
direction  of  the  line  of  fracture,  and  the  size  and  shape  of  the 
lower  fragment.  The  skeleton  drawing  in  the  accompanying 
diagram  represents  pretty  accurately  the  line  of  separation 


FIG.  56. 


Fracture  through  the  lower  extremity  of  the  radius,  showing  the  tendency  of  the 
hand  to  slide  away  from  the  ulna. 

just  above  the  radio-carpal  articulation.  The  short  fragment 
is  larger  in  some  instances  and  smaller  in  others.  It  is  well 
to  bear  in  mind,  while  considering  the  relative  positions  the 
fragments  take,  that  the  supinator  lougus  is  inserted  into  the 
lower  fragment,  dragging  it  and  the  carpus  attached  to  it, 
away  from  the  ulna,  and  the  pronator  quadratics  drags  the 
lower  end  of  the  upper  fragment  toward  the  ulna,  making  the 
arm  just  above  the  wrist  rounder,  or  less  flattened,  than  usual. 

Colles'  fracture  of  the  radius  happens  at  all  periods  of  life. 
from  infancy  to  old  age.  Females  not  bring  so  much  exposed 
to  the  violent  accidents  of  life  as  the  other  sex,  suft'er  less  from 
all  kinds  of  fractures.  In  September,  1868,  a  gentleman  and 
two  ladies  were  thrown  from  a  carriage,  while  riding  on  the 
Reading  pike.  The  gentleman  jumped  before  the  carriage 
had  fully  upset,  and  landing  heavily  on  one  foot^-eceived 
Pott's  fracture  of  the  fibula;  the  two  ladies  were  hurled  vio- 
lently to  the  earth,  with  hands  extended  to  save  more  vital 
parts,  and  each  sustained  a  fracture  of  the  right  radius  near 
the  wrist.  If  sex  had  any  bearing  on  these  injuries,  it  must 
have  been  confined  to  the  conduct  of  each  in  an  emergency, 
the  man  preferring  the  risks  of  a  leap  to  the  more  passive 
course  of  being  thrown  upon  his  hands  and  head. 

The  deformities  following  Colles'  fracture  present  unmis- 
takable characteristics,  whether  treated  well  or  ill,  or  not 


OF  THE  RADIUS.  153 

treated  at  all.  Some  years  ago  I  examined  the  wrists  of  Mr. 
Coleman,  an  English  gentleman,  who  on  a  voyage  from  Cal- 
cutta to  New  York,  was  thrown  against  some  luggage  by  a 
violent  lurch  of  the  ship.  He  received  the  common  fracture 
of  the  radius  in  both  arms,  and  as  there  was  no  surgeon  on 
the  vessel,  no  treatment  was  instituted  except  the  application 
of  a  wet  cloth  to  keep  down  inflammation.  Being  injured  off 
the  Cape  of  Good  Hope,  it  was  several  weeks  before  he  arrived 
in  port.  It  was  then  too  late  to  have  anything  done  to  remedy 
the  deformity.  However,  the  wrists  were  fully  as  mobile  and 
useful  at  the  end  of  two  months  from  the  injury  as  they 
would  have  been  if  subjected  to  the  usual  treatment,  and  the 
deformities  were  not  greater  than  in  many  cases  which  have 
passed  through  surgical  hands.  I  was  •surprised  to  see  no 
worse  results  in  cases  never  treated. 

The  examination  of  cabinet  specimens  reveals  the  fact  that 
there  is  more  or  less  impaction  in  many  cases,  the  upper  frag- 
ment being  driven  into  the  lower.  In  one  specimen  belonging 
to  me,  taken  from  the  arm  of  a  man  who  was  killed  by  a  fall, 
the  lower  fragment  is  split  into  three  pieces,  the  line  of  frac- 
ture running  through  the  carpal  articular  surface ;  and  to  every 
appearance  the  comminution  was  produced  by  the  impacting 
and  wedging  forces  of  the  upper  fragment.  The  primary 
fracture  was  about  an  inch  above  the  carpo-radial  articulation; 
the  splitting  of  tne  lower  fragment  must  have  been  of  a 
secondary  nature,  and  was  probably  produced  by  the  impetus 
of  the  body  after  the  hand  had  struck  the  earth  and  received 
the  earliest  lesion. 

The  symptoms  of  fracture  of  the  radius  near  the  wrist  are, 
pain,  swelling,  greater  or  less  inability  to  use  the  hand  and 
arm,  and  all  the  deformities  already  described.  Crepitus  can 
not  always  be  produced,  though  the  cases  are  rare  in  which  it 
can  not  be  elicited  by  varied  manipulation.  In  young  subjects 
the  result?  of  well  treated  cases  are  quite  satisfactory,  but  in 
elderly  persons,  some  degree  of  anchylosis,  and  stiffness  in  the 
wrist  and  fingers,  lasts  for  weeks,  months,  and  even  years. 
The  sheaths  of  the  tendons  lose  their  slippery  functions,  and 
a  troublesome  sensitiveness  chronically  affects  the  hand  and 
wrist. 

TREATMENT. — Many  ingenious  contrivances  have  been  de- 
vised for  successfully  treating  fractures  through  the  lower 


154  FRACTURES. 

third  of  the  radius.  In  fact,  some  of  our  works  on  fractures 
contain  so  many  plans,  with  lengthily  expressed  approvals  and 
objections,  that  the  inexperienced  reader  finds  some  difficulty 
in  selecting  the  most  feasible  plan.  It  is  thought  best,  there- 
fore, to  describe  a  simple  method  of  dressing  the  arm,  which 
can  be  readily  put  in  practice  in  the  country,  where  a  thin 
board,  knife,  and  bandage  can  be  obtained.  The  dorsal  splint 
may  be  a  piece  of  cigar  box,  two  and  a  half  inches  wide  and 
long  enough  to  reach  from  near  the  elbow  to  the  back  of  the 
hand.  Before  application  it  should  be  wound  with  strips  of 
muslin  or  old  cloth;  the  palmar  splint  may  be  whittled  from 
the  thin  cover  of  a  box,  or  from  a  shingle,  or  lath.  Its  shape 
may  be  something  like  the  profile  of  the  hand  and  arm,  or 
like  that  represented  by  No.  1  in  figure  57,  which  is  broad 
near  the  lower  end,  and  cut  obliquely  across,  so  that  the  upper 
or  longest  border  corresponds  with  the  thumb  side  of  the  hand. 
To  this  broad  and  obliquely  cut  extremity  a  compress  large 
enough  to  fill  the  hollow  of  the  hand,  is  bound.  The  com- 
press may  be  made  of  a  strip  of  bandage,  compactly  rolled. 
This  is  to  be  fastened  in  place  by  the  same  strip  which  is  used 
to  envelope  the  splint.  The  obliquity  of  the  compress  when 
the  splint  is  applied,  forces  the  hand  to  the  ulnar  side,  thereby 
producing  a  degree  of  extension  upon  the  lower  fragment. 

A  compress  is  placed  between  the  splint  and  the  prominence 
of  the  arm  on  the  palmar  surface,  and  another  small  compress 
is  placed  on  the  prominence  of  the  back  of  the  wrist,  under 
the  dorsal  splint.  A  piece  of  tape  is  tied  around  the  splints 
near  the  hand,  and  another  near  the  elbow,  to  retain  the 
dressings  thus  far  applied,  in  place.  Extension  is  now  made 
on  the  fingers  to  adjust  the  fragments  ;  and  the  lower  tape  is 
tightened  to  prevent  the  displacement  from  recurring.  Over 
the  whole  dressing  thus  far  applied  a  roller  bandage  is  snugly, 
though  not  tightly  wrapped.  Figure  57  represents  the  t\vo 
splints  before  they  are  applied,  and  the  arm  after  it  is  fully 
dressed.  The  fingers  and  thumb  are  left  exposed,  and  can  be 
used  enough  to  prevent  anchylosis,  or  even  much  stiffness. 
This  dressing  is  simple  in  its  construction,  easily  worn,  and 
prevents  motion  between  the  fragments.  I  have  obtained 
better  results  with  it  than  with  more  complicated  and  expen- 
sive apparatus.  The  width  of  the  splints  must  always  exeeed 
the  width  of  the  arm  in  order  that  there  shall  be  no  circular 


OF  THE  RADIUS. 


155 


constriction.  No  enveloping  bandage  is  to  be  used  upon  the 
arm  before  the  splints  are  applied.  No  water  or  other  topical 
application  is  to  be  employed,  for  the  wetting  of  the  bandage 


FIG.  57. 


No  1  is  the  palmar  splint  re.-uly  for  use ;  and  Xo.  2  the  dorsal  splint.    The  arm  is  represented 
as  dressed  in  the  treatment  of  "  Colles'  fracture     of  the  radius. 

shrinks  the  cloth,  and  makes  the  dressing  too  tight.  The  limb 
should  be  seen  the  next  day  after  the  accident,  and  the  bund- 
age  loosened  if  it  seem  to  inflict  pain  or  to  arrest  the  circula- 
tion. It  is  better  to  re-dress  the  limb  than  to  take  any  risk  o : 
mischief  from  strangulation.  After  the  swelling  has  subsided, 
which  will  be  in  eight  or  ten  days  after  the  accident,  the 
dressing  may  be  left  undisturbed  for  a  week  at  a  time.  In 
four  or  five  weeks,  as  a  general  rule,  the  consolidation  will 
be  complete,  and  the  dressings  may  be  laid  aside.  However, 
passive  motion  should  be  kept  up  for  several  weeks  longer  or 
until  the  functions  of  the  fingers  and  wrist  are  re-established. 
Persons  advanced  in  years  are  liable  to  neuralgic  pains  in  the 
hand  and  at  the  seat  of  injury.  This  difficulty,  if  prolonged, 
and  much  troublesome,  may  be  ameliorated  by  the  use  of 
stimulating  and  anodyne  liniments.  The  excess  of  reparative 
material  sometimes  thrown  out  around  the  end  of  the  upper 
fragment,  constitutes  a  hard  ridge  at  the  seat  of  fracture,  and 
seriously  impedes  the  play  of  the  tendons  in  that  region.  In 
time  this  excess  of  callus  will  be  absorbed,  leaving  the  parts 
nearly  in  their  normal  state. 

An  impending  evil  after  fracture  of  the  radius  near  the 
wrist,  is  false  joint,  which  generally  occurs  where  the  patient 
has  used  the  fore-arm  at  too  early  a  period,  or  where  motion 
at  the  wrist  has  not  been  guarded  against  during  the  treat- 
ment. Two  ordinary  straight  splints,  though  they  extend  be- 
yond the  fingers,  do  not  restrain  motion  at  the  seat  of  fracture 


156 


FRACTURES. 


as  well  as  the  palmar  splint,  with  its  roller-like  compress  for 
the  hollow  of  the  hand.  The  dorsal  splint  resting  upon  the 
back  of  the  hand  also  serves  to  check  that  tilting  motion, 
with  the  lower  end  of  the  ulna  for  a  pivot,  which  is  so  promo- 


tive  of  non-union  of  the  fragments. 

FIG.  58. 


The  arm  exhibits  the  deformity  attendant  upon  fracture  through  the  lower  extremity  of  the 
radius.    A  single  splint,  like  the  one  represented,  will  answer  to  dress  the  fracture. 


Some  surgeons  employ  only  one  splint  in  the  dressing  for 
fracture  through  the  lower  extremity  of  the  radius  ;  and  claim 
to  have  obtained  good  results  from  such  an  appliance.  I  have 
secured  satisfactory  recoveries  from  the  single  splint,  with  a 
roller  bound  obliquely  upon  the  wide  end,  to  rest  in  the  hollow 
of  the  hand,  but  I  prefer  using  also  a  dorsal  splint. 

If  the  dressing  gets  too  loose,  and  the  patient  begins  to  use 
the  hand  before  the  consolidation  is  quite  effected,  the  vital 
operations  are  perverted.  Instead  of  continuing  to  furnish 
reparative  supplies,  they  begin  to  remove  tbe  callus  or  uniting 
material,  and  make  way  for  false-joint.  In  one  case  that  came 
under  my  observation,  the  consolidation  was  nearly  perfect  on 
the  twentieth  day  ;  there  was  plenty  of  callus,  and  every  evi- 
dence of  a  complete  repair.  The  patient  now  thought  it  was 
all  useless  to  hamper  his  arm  any  longer,  and  assumed  the  re- 
sponsibility of  throwing  aside  the  dressing  and  using  the  arm. 
At  once  the  operations  of  nature  became  opposed  to  consoli- 
dation, and  in  a  few  weeks  removed  the  reparative  material 
and  established  a  false-joint  where  there  might  have  been  con- 
solidation by  a  week  more  of  retentive  treatment. 


OF  THE  RADIUS. 


157 


A  little  girl  was  brought  to  me  not  long  since  with  an  arm 
that  had  been  fractured  through  the  lower  extremity  of  the 
radius  five  weeks  previously.  The  medical  attendant  had 
divssed  the  limb  in  the  usual  wav,  but  the  dressing  had  been 
loosened  by  the  child's  mother,  and  taken  off  altogether  before 
the  physician  had  given  directions  for  such  a  course.  The 
little  girl  had  used  her  arm  at  play,  keeping  up  motion  at  the 
seat  of  injury  where  there  should  be  absolute  rest.  The  con- 
sequence was  that  the  fragments  failed  to  unite,  though  the 
upper  fragment  furnished  an  abundance  of  reparative  material. 
I  regarded  it  as  not  too  late  for  an  attempt  to  re-establish  the 
healing  process,  so  I  put  on  the  dressing  recommended  for 
the  treatment  of  this  fracture,  employing  starch  paste  at  each 
turn  of  the  bandage.  In  fact,  the  roller  was  employed  up  and- 
down  the  arm  two  or  three  times,  and  the  paste  freely 
applied,  as  the  wrapping  continued,  to  constitute  an  immov- 
able dressing.  The  rigid  case  thus  constructed,  was  ordered 
to  be  worn  six  weeks  at  least.  Consolidation  followed,  and  a 
good  result  was  obtained. 


FRACTURE  OF  BOTH  BONES  OF  THE  FORE-ARM. 

The  radius  and  ulna  are  often  broken  at  the  same  time. 
The  injury  is  produced  by  direct  violence.  A  blow,  the  pas- 
sage of  a  wheel  over  the  arm,  and  moving  machinery,  are  the 

FIG.  50. 


Fracture  of  the  railiu*  ;<n<l  \iln:i.    The  snme  muscles  are  shovra  as  acting 
u|M.n  the  fragments  as  when  oue  bone  is  broken. 

common  causes.  The  middle  and  lower  extremities  of  the 
bones  are  broken  more  frequently  than  the  upper  thirds  which 
are  protected  in  a  measure  by  the  deep  coverings  of  muscles. 
In  regard  to  the  frequency  of  such  accidents,  the  analysis  of 


158 


FRACTURES. 


tables  shows  that  both  bones  of  the  fore-arm  are  oftener 
broken  than  the  ulna  singly. 

The  diagnosis  is  usually  simple;  the  pain,  loss  of  power,  the 
unnatural  bend  in  the  arm,  the  separate  mobility  of  the  upper 
and  lower  fragments,  and  the  crepitus,  constitute  signs  which 
are  too  plain  to  be  mistaken.  The  displacement  of  the  frag- 
ments may  not  be  observable  in  some  instances,  for  the  broken 
ends  do  not  always  become  disengaged,  but  in  most  eases  the 
deformity  is  so  great  as  to  indicate  at  once  the  nature  of  the 
injury.  When  there  is  overlapping  of  the  fragments  there 
must,  of  necessity,  be  shortening  of  the  arm.  The  peculiar 
distortion  produced  by  bending  the  limb  near  the  seat,  of  frac- 
ture, can  not  be  misapprehended.  Crepitus  can  be  elicited  by 
grasping  the  arm  above  and  below  the  fracture,  and  rotating 
the  limb  while  it  is  brought  to  its  normal  length  and  position 
by  extension. 

The  tendency  of  the  fragments  is  to  sink  into  the  inter- 
osseous  space,  where  they  will  unite  en  masse  unless  well 
directed  efforts  are  made  to  keep  the  ends  of  the  two  bones 
away  from  each  other.  In  some  instances  one  fragment  will 
keep  aloof  from  the  others  which  incline  to  group.  If  the 
bones  be  broken  conjointly  and  by  direct  violence,  much 
damage  may  be  done  to  the  soft  tissues,  resulting  in  sloughs, 

FIG.  60. 


Comminuted  fracture  of  both  bones  of  the  forearm. 

protrusion  of  the  fragments,  and  the  most  dangerous  compli- 
cations. Compound  and  comminuted  fractures  of  both  bones 
of  the  fore-arm  have  generally  been  considered  a  sufficient 
cause  for  immediate  amputation,  but  such  a  course  is  not 
always  necessary,  as  the  following  case  will  show.  In  October, 
1865,  Mr.  William  Moffit,  living  on  Longworth  Street  in  this 


OF    THE    FORE-AP.M. 


159 


city,  had  his  arm  drawn  between  the  rollers  of  a  leather  split- 
ting machine.  The  crushing  power  to  which  the  limb  was 
subjected,  broke  the  radius  and  ulna  into  fragments,  each  an 
inch  or  two  in  length,  beginning  near  the  wrist  and  extending 
to  the  elbow.  The  arm  felt  like  a  bag  with  pieces  of  broken 
ice  in  it.  Some  of  the  pieces  of  bone  projected  through  the 
skin.  Dr.  E.  N.  Gushing,  of  Covington,  Ky.,  was  in  my  office 
at  the  time  I  was  summoned  to  the  case,  and  assisted  in  ar- 
ranging and  adjusting  the  fragments,  and  in  dressing  the 
limb.  It  is  needless  to  say  that  it  was  utterly  impossible  to 
bring  every  fragment  into  perfect  apposition  at  both  ends,  but 
the  fragments  of  the  two  bones  were  pressed  into  rows,  and 
the  natural  contour  of  the  limb  was  well  restored  and  preserved. 
Splints  and  bandages  were  used  to  keep  the  pieces  and  parts 
steadily  in  place.  No  severe  pressure  was  applied  through 
fear  of  gangrene.  In  less  than  two  months  the  arm  Avas  freed 
from  its  dressings,  and  put  under  passive  motion.  The  limb 
lost  only  a  small  share  of  its  functions,  and  therefore  became 
quite  useful.  Pronation  and  supination  were  partly  lost ;  and 
the  elbow  and  wrist  did  not  recover  their  full  extent  of 
motion. 

In  treating  fractures  of  both  bones  of  the  fore-arm,  two 
splints  reaching  from  the  elbow  to  the  wrist,  and  Avide  enough 

Fia.  61. 


Two  splints,  wider  than  the  arm,  and  padded,  are  represented  as  tied  in  place  with  tapes 
preparatory  to  the  reception  of  the  roller  or  circular  bandage. 


to  prevent  circular  constriction  of  the  arm,  are  to  be  em- 
ployed upon  the  front  and  dorsal  aspects  of  the  limb.  Tapes 
may  be  used  to  retain  the  dressing  in  place  until  the  frag- 
ments are  coaptated,  and  everything  is  ready  for  the  roller 
bandage.  As  in  all  other  fractures  of  the  fore-arm,  no  primary 
bandage  is  to  go  on  next  the  skin.  The  constricting  influence 
of  such  a  bandage  would  force  the  fragments  into  the  inter- 
osseous  space  Avhere  they  are  liable  to  unite  in  a  group. 
The  retentive  bandage  should  be  applied  lightly  at  first. 


160  FRACTURES. 

Several  cases  are  recorded  in  which  the  limb  has  had  to  be 
amputated,  through  the  folly  or  carelessness  of  too  tight 
dressings.  There  is  time  enough  for  snug  compression  after 
inflammation  and  swelling  have  subsided.  Inexperienced 
surgeons  often  commit  the  error  of  strangling  the  local  circu- 
lation by  a  tightly  drawn  retentive  dressing.  There  is  no 
other  excuse  for  these  repetitions  in  regard  to  the  application 
of  dressings  to  a  broken  arm,  except  in  the  fact  that  serious 
and  fatal  mistakes  continue  to  be  made  by  practitioners  of 
medicine  and  surgery  who  have  either  not  had  an  opportunity 
to  read  impressive  lessons  on  the  subject,  or  they  are  too  heed- 
less to  learn  what  is  enjoined  but  once. 

A  girl,  Miss  S.,  had  her  arm  broken  while  at  work  at  a 
printing  press.  The  physician  under  whose  professional  charge 
the  patient  fell,  wrapped  the  limb  from  the  fingers  to  the  ax- 
illa with  new  and  thick  drilling,  and  then  ordered  the  wrap- 
pings kept  wet  all  the  time.  Morphia  and  chloral  were  ad- 
ministered to  keep  pain  in  check.  Two  days  after  the  injury 
I  saw  the  case  and  advised  amputation,  as  gangrene  had  ap- 
peared from  the  fingers  to  a  distance  above  the  elbow.  My 
plan  was  rejected,  and  the  late  Dr.  Geo.  C.  Blackmail  was  in- 
vited to  manage  the  case.  The  doctor  said  at.  once  the  arm 
could  and  must  be  saved,  and  the  patient  was  taken  to  the 
Good  Samaritan  Hospital.  In  a  few  days  the  arm  dropped 
from  the  scapula,  unaided  amputation  having  occurred  at  the 
shoulder  joint.  The  separation  was  attended  by  no  bleeding 
or  other  mishap.  The  cicatricial  line  was  nicely  puckered, 
and  every  feature  of  the  reparative  process  was  admirable. 
The  dead  arm  gave  issue  to  a  horrible  stench  while  the  sepa- 
ration at  the  shoulder  was  going  on,  yet  the  surgeon  had  given 
his  word  that  no  amputation  was  necessary,  and  he  was  ob- 
stinate enough  to  stick  to  it.  The  case  shows  what  the  unas- 
sisted recuperative  powers  of  the  body  will  accomplish  when 
left  to  themselves. 

A  similar  case  occurred  in  Lowcil,  Mass.,  twenty-five  years 
ago.  When  the  results  of  unskillful  bandaging  had  appeared, 
surgeons  gathered  with  the  idea  of  amputating,  but  gave  up 
their  purpose  on  the  ground  that  the  patient  would  not  sur- 
vive the  operation.  In  less  than  a  week  the  head  of  the  hu- 
merus  dropped  from  its  socket,  and  in  two  days  more  all  the 
soft  tissues  became  disconnected  at  the  border  of  the  axilla. 


CHAPTER    XXIII. 


The  bones  of  the  hand,  including  the  carpus,  metacarpus, 
and  phalanges,  are  seldom  broken.  The  carpus  has  no  long 
bones,  but  a  group  of  eight  pieces,  rounded  and  angular, 
which  are  held  together  by  ligaments  and  other  fibrous  struc- 
tures, so  that  even  if  one  or  more  were  broken  or  crushed, 
there  would  be  no  particular  displacement  or  special  signs  of 
fracture.  It  would  be  more  in  accordance  with  a  rational 
division  of  subjects  if  fractures  of  the  carpus  were  arranged 
under  the  head  of  wounds  or  severe  bruises.  The  carpal 
bones  can  not  be  broken  unless  by  direct  violence  of  a  crush- 
ing character,  as  by  the  passage  over  the  wrist,  of  a  cart- 
wheel, or  by  being  caught  between  the  hunters  of  rail -cars. 

The  treatment  should  consist  in  adjusting  displaced  parts  as 
well  as  possible,  and  in  using  a  bandage  upon  the  hand,  wrist, 
and  fore-arm,  to  restrain  motion.  The  topical  use  of  anodynes 
and  cooling  lotions,  would  be  indicated.  In  the  management 
of  a  gunshot  wound  of  the  wrist,  in  which  there  must  have 
been  a  crushing  of  one  or  more  carpal  bones,  my  patient  ex- 
hibited signs  of  tetanus.  Chloroform  constantly  applied  to 
lint  laid  upon  the  wound,  seemed  to  allay  the  nervous  irrita- 
tion. 

FRACTURE  OF  THE  METACARPAL  BONES. 

Direct  violence  upon  the  back  of  the  hand,  and  indirect 
force,  as  by  blows  upon  the  ends  of  the  knuckles  in  pugilistic 
encounters,  may  produce  fracture  of  one  or  more  of  the  meta- 
carpal  bones.  I  have  treated  cases  that  were  produced  by 
both  causes.  Two  years  ago,  John  Benson,  of  West  Virginia, 
came  to  my  office  one  morning  with  the  right  hand  swollen 
11  (161) 


162 


FRACTURES. 


and  very  painful.  About  sunrise  that  morning,  he  got  into  a 
fight  with  a  negro  deck  hand  on  the  Annie  Laurie.  He  says 
he  struck  at  his  assailant,  and  missing  him,  his  knuckle  hit  a 
box  of  freight ;  something  in  his  hand  cracked  like  a  pistol, 
and  his  hand  became  too  painful  to  use.  At  the  middle  of 
the  metacarpal  bone  of  the  ring  finger  a  tumefaction  existed, 
and  back  and  forward  pressure  produced  motion  between  the 
fragments  of  the  broken  bone,  and  elicited  crepitus. 

In  June  last  a  boy  came  to  my  office  from  the  printing  de- 
partment of  Stannage  &  Co.,  and  complained  bitterly  of  his 
hand,  which  had  been  injured  in  a  printing  press.  I  found 
three  of  the  metacarpal  bones  broken,  and  the  first  phalanx 

FIG.  62. 


Fracture  of  three  of  the  metacarpal  bones,  and  the  first  phalanx  of  the  thumb. 
The  hand  was  crushed  in  a  printing  press. 

of  the  thumb.  I  applied  to  the  hand  and  arm  the  palmar 
splint  used  for  fracture  of  the  lower  extremity  of  the  radius, 
and  retained  it  in  place  with  a  bandage.  The  injury  proved 
to  be  very  painful,  and  the  inflammation  ran  high.  The  back 
of  the  hand  was  kept  wet  with  the  tincture  of  aconite.  At 
the  end  of  three  weeks  the  dressings  were  removed,  at  which 
time  the  consolidation  seemed  to  be  complete.  However,  the 
stiffness  of  the  metacarpo-phalangeal  joints  was  so  great  that 
forcible  passive  motion  had  to  be  employed  for  weeks,  before 
the  functions  were  sufficiently  restored  to  allow  of  his  volun- 
tarily opening  and  shutting  the  hand.  Slight  displacement 
of  the  fragments  toward  the  palm  existed  at  the  time  I  first 
saw  the  hand,  and  this  deformity  was  not  entirely  overcome 
by  the  treatment.  The  boy  was  so  stubborn  and  refractory 
that  I  could  not  carry  out  my  plan  of  treatment  fully.  He 
objected  to  a  moderately  tight  dressing,  and  would  not  submit 
to  efficient  passive  motion.  In  treating  fractures  of  the  meta- 
carpal bones,  the  plan  of  causing  the  hand  to  grasp  a  large 


OF  THE  PHALANGES.  163 

hall,  and  then  binding  a  roller  around  the  whole,  as  recom- 
mended by  Sir  Astley  Cooper,  is  not  so  valuable  as  the  palmar 
splint,  with  a  roller  compress  bound  to  its  end  obliquely,  to 
iill  the  hollow  of  the  hand.  This  dressing  leaves  the  fingers 
free,  and  prevents  the  ends  of  the  fragments  from  sinking 
down  toward  the  palm.  If  the  metacarpal  bone  of  the  thumb 
be  broken  singly,  the  palmar  splint  having  the  roller  com- 
press attached,  is  the  best  apparatus  that  can  be  employed  to 
give  the  fragments  support  and  prevent  motion  and  displace- 
ment. 

FRACTURE   OF  THE   PHALANGES. 

From  the  exposed  situation  of  the  bones  of  the  fingers, 
fracture  of  one  or  more  of  the  phalanges  is  an  occasional  in- 
jury demanding  consideration.  Direct  violence  is  by  far  the 
most  common  cause  of  the  lesion,  though  a  blow  upon  the 
end  of  a  finger,  as  in  attempts  to  stop  or  catch  a  ball,  may 
produce  fracture  of  the  first  or  second  phalanx. 

A  simple  fracture  of  the  finger  may  be  produced  by  the 
great  velocity  of  the  force  applied.  The  phalanges  have  been 
broken  by  a  smart  blow  of  a  cane,  though  no  resistance  was 
offered  on  the  opposite  side  of  the  fingers.  A  phalanx  is 
seldom  broken  in  more  than  one  place,  and  generally  near  the 

FIG.  63. 


Fracture  of  a  digital  phalanx. 

middle.  A  crushing  force  not  uufrequently  produces  a  com- 
minution of  the  bone,  including  its  articular  extremities,  and 
perforation  of  the  integuments. 

The  symptoms  of  simple  fracture  are  crepitus  and  mobility 
of  the  fragments  ;  sometimes  the  shape  of  the  finger  will  de- 
termine whether  it  is  broken  or  not.  If  the  flesh  be  mashed 
and  the  bone  crushed,  one  of  the  joints  of  the  finger  is  about 
sure  to  be  involved ;  and  the  symptoms  must  depend  very 
much  upon  the  severity  of  the  injury. 

TREATMENT. — Simple  fracture  of  a  finger  is  to  be  managed 
on  the  usual  plans  followed  in  treating  the  long  bones.  A 


164  FRACTURES. 

narrow  straight  wooden  splint  is  fastened  btneath  the  finger, 
with  a  small  compress  against  the  point  of  fracture  to  support 
the  ends  of  the  broken  bone,  and  to  fill  up  the  concavity  which 
naturally  exists  between  the  joints.  A  strip  of  pasteboard 
laid  upon  the  dorsal  surface  of  the  linger,  offers  moderate  re- 
sistance to  motion  between  the  fragments,  and  serves  to  keep 
the  bandage  from  constricting  the  integument.  At  the  end 
of  the  third  or  fourth  week,  when  the  dressing  is  finally  re- 
moved, well  directed  passive  motion  is  needed  to  get  rid  of 
the  stillness  which  depends  upon  deposits  of  lymph  in  the 
sheaths  of  the  tendons. 

Broken  fingers  left  to  themselves,  without  treatment,  do  not 
turn  out  well.  They  become  angularly  deformed,  deflected 
laterally,  or  rotated  on  their  axis,  constituting  permanent  de- 
formities that  are  sources  of  much  regret  to  the  patient  ever 
afterwards.  I  have  been  solicited  to  break  a  deviated  finger, 
and  attempt  to  straighten  it.  I  have  never  seen  a  case  that 
seemed  to  justify  the  measure,  though  such  an  operation 
would  not  always  be  unwarranted. 

Compound  fractures  of  the  fingers,  with  mashing  of  the 
soft  parts,  can  sometimes  be  brought  into  proper  shape  by  the 
use  of  sticking  plaster.  Such  injuries,  however,  do  not  prop- 
erly come  under  the  head  of  fractures,  so  far  as  adjustment 
and  treatment  are  concerned,  but  must  be  managed  according 
to  the  principles  involved  in  the  treatment  of  wounds. 


CHAPTER    XXIV. 
FRACTURE  OF  THE  PELVIC  BONES. 


Crushing  forces,  as  when  a  man  is  caught  between  heavy 
moving  bodies,  or  strikes  in  the  region  of  the  hip  at  the  ter- 
mination of  a  long  fall,  may  produce  fracture  of  some  part  of 
the  pelvic  circle.  The  symphysis  pubis  has  been  separated 
by  the  throes  of  labor,  though  such  an  accident  must  be  ex- 
ceedingly uncommon.  Several  cases  have  been  reported  in 
v/hicli  forcible  separation  of  the  two  pubic  bones  occurred  at 
the  symphysis  from  injuries  received  while  coupling  cars,  and 
in  railway  accidents  generally.  I  was  once  called  to  see  an 
old  negro  in  Louisiana,  who  had  been  kicked  by  a  mule  in  the 
region  of  the  pubes.  He  was  unable  to  urinate,  and  while 
introducing  the  catheter  I  discovered  a  sinking  in  of  the  body 
of  the  os  pubis  on  the  left  side,  at  a  point  outside  of  the  spine 
of  the  bone.  The  line  of  separation  must  have  extended  into 
the  thyroid  foramen,  though  the  ramus  of  the  pubis  did  not 
appear  to  be  broken.  The  fractured  surface  of  the  end  of  the 
outer  fragment  could  be  distinctly  felt,  but  the  other  surface 
was  too  much  depressed  to  be  manipulated.  ]Sro  mobility  ex- 
isted, and  on  account  of  the  swelling  no  deformity  was  ob- 
served until  in  the  attempt  at  catheterism  the  left  wrist  dis- 
covered an  irregularity  of  the  parts.  The  patient  was  not 
aware 'that  a  fracture  had  been  received,  but  supposed  his 
bladder  was  ruptured.  The  urine  was  not  bloody,  and  there 
was  no  evidence  that  severe  internal  injury  had  been  inflicted. 
The  depressed  bone  could  not  be  brought  back  into  place ; 
yet  some  months  afterwards  I  heard  that  the  patient  suffered 
no  inconvenience  from  his  injuries. 

Fractures  of  the  pelvic  bones  are  not  necessarily  dangerous 
of  themselves  ;  but  the  terrible  forces  which  produce  them  are 
apt  to  inflict  greater  or  less  injury  to  important  parts  in  their 

(165) 


166 


FRACTURES. 


immediate  vicinity.  Fragments  of  bone  may  perforate  the 
rectum  and  bladder,  or  do  such  mischief  to  the  viscera  of  the 
pelvis  as  may  seriously  interfere  with  the  functions  of  those 
organs.  The  gravity  of  such  injuries  can  not  always  be  de- 
termined at  the  earlier  examinations.  The  crest  of  the  ilium, 
and  the  anterior  superior  spinous  process  may  be  broken  off 
by  moderate  forces,  as  by  a  kick  from  another  individual,  but 
the  massive  strength  of  the  deeper  parts  and  their  protective 
coverings  and  connections,  serve  to  shield  them  from  the 
damaging  influence  of  all  ordinary  forces. 

In  1860,  Andy  Rice,  in  the  employ  of  Mcllenry  &  Carson, 
fell  through  the  hatches  of  four  stones,  and  struck  against, 
hard  substances  in  the  cellar.  He  sustained  a  multiplicity  of 
injuries,  and  fully  recovered  from*  all  of  them.  At  first  he 
complained  most  of  his  left  shoulder,  which  was  dislocated. 
This  I  reduced  without  removing  his  coat  or  chana-ini;1  \\\< 
position.  Finding  that  he  had  several  fractures  1  had  him 
taken  home.  I  there  learned  by  examination  that  one  femur 
was  broken  just  below  the  lesser  trocanter;  that  the  under 
jaw  was  broken  at  the  symphysis  ;  that  three  ribs  were  frac- 
tured;  and  that  the  left  os  innominatum  was  broken  into  at 
least  three  pieces.  It  was  difficult  to  determine  just  \vhere 
F  ^  all  the  lines  of  separation  ex- 

tended. The  great  arc  of  the 
ilium  could  be  easily  moved 
by  taking  hold  of  it,  and 
the  motions  were  attended 
with  distinct  crepitus.  Its  line 
of  separation  must  have  been 
nearly  like  the  upper  one  repre- 
sented in  the  accompanying 
figure.  The  movement  of  this 
piece  gave  little  pain  ;  but  in 
attempts  to  diagnose  the  other 
fractures  of  the  innoniinatmii 
great  distress  \vas  produced. 
The  greatest,  degree  of  pain 
seemed  to  arise  from  motion 
imparted  to  the  fragments  of 

the  femur.     The  pubic  part  of  the  bone  was  certainly  hroken 
through  the  rain  us  and  hodv.     This  left,  the  femur  articulate.  I 


Fractures  cf  the  os  innominatum. 


OF  THE  SACRUM.  167 

to. a  large  movable  fragment  of  the  innominatuni,  that  was 
free  from  still  another  fragment  which  was  firmly  united  to 
the  sacrum.  The  costal  segment  was  the  most  mobile,  then 
the  large  piece  that  contained  the  acetabulum ;  the  smaller 
fragment  connected  to  the  sacrum  had  no  perceptible  mobility, 
and  the  pubic  fragment  continued  firm  on  account  of  its  junc- 
tion at  the  symphysis.  The  catheter  had  to  be  used  a  few 
times,  but  there  was  no  blood  in  the  urine.  The  symptoms 
were  so  terribly  severe  for  more  than  a  week  that  there  seemed 
little  ground  for  hope.  The  pelvis  now  has  its  natural  shape, 
excepting  a  slight  abnormal  twist  in  the  left  os  innominatuni, 
which  does  not  cause  lameness. 

The  treatment  of  fracture  of  the  pelvic  bones  consists  in 
applying  such  bandages,  straps,  belts,  or  apparatus,  as  shall 
restrain  all  motion  between  the  fragments.  In  the  case  of 
Andy  Rice  I  used  the  "  woven  wire  breeches,"  figure  10. 
This  apparatus  served  several  purposes:  1st,  to  keep  up  ex- 
tension and  counter-extension  for  the  fractured  thigh  ;  2d,  to 
steady  the  pelvic  fragments  ;  and  3d,  it  proved  useful  in  hand- 
ling the  patient  during  the  six  weeks  of  treatment. 

A  wide  belt  of  strong  cloth  or  leather  to  buckle  around  the 
pelvic  region,  serves  to  steady  a  simple  fracture  of  the  ilium, 
ischium,  or  pubes.  The  patient  is  unable  to  walk,  or  to  assume 
the  erect  posture,  if  anything  more  than  a  salient  point  is 
broken  from  the  pelvic  bones.  The  powerful  muscles  acting 
upon  any  considerable  fragment,  would  disturb  it  too  much 
for  active  exercise. 

Fracture  extending  into  the  acetabulum,  seriously  interferes 

O  */ 

with  the  hip-joint;  and  the  diagnosis  of  such  an  injury  must 
be  exceedingly  obscure.  Cases  have  been  dissected  in  which 
it  had  been  demonstrated  that  a  stellate  fracture  of  the  ace- 
tabulum was  produced  by  a  blow  upon  the  trochanters 
of  the  femur,  the  force  telling  through  the  head  of  that  bone. 


FRACTURE   OF   THE   SACRUM. 

The  sacrum,  as  a  dry  specimen,  removed  from  its  connec- 
tions with  the  other  pelvic  bonos,  is  not  difficult  to  break,  but 
in  its  normal  state,  wedged  between  the  ossa  innominata,  and 
covered  with  ligamentons  and  other  firm  tissues,  the  bone  is 


168  FRACTURES. 

in  little  danger  of  being  broken.  A  kick  or  a  powerful  blow, 
such  as  may  be  received  in  a  full,  might  cause  a  fracture  of 
the  bone  at  any  point,  the  line  of  separation  running  in  any 
direction.  The  processes  of  the  bone  may  be  broken  oft',  or  a 
fracture  may  extend  only  as  far  as  the  central  or  spinal  canal. 
In  most  instances,  it  is  found  that  fractures  of  the  sacrum  ex- 
tend through  the  lower  third  of  the  bone,  and  mostly  in  a 
transverse  course. 

If  the  lower  fragment  be  carried  in  towards  the  rectum  the 
functions  of  that  tube  might  be  seriously  interfered  with.  A 
patient  suspected  of  having  a  broken  sacrum  should  be  made 
to  lie  on  the  abdomen  while  an  examination  is  going  on,  and 
an  attempt  made  to  overcome  any  considerable  displacement. 
The  finger  carried  into  the  .rectum  may  be  the  only  means  of 
discovering  the  full  extent  of  the  mischief,  and  in  correcting 
such  deformity  as  lays  within  digital  power.  A  lithotoniist's 
scoop,  or  any  instrument  of  proper  proportions  and  strength, 
might  be  used  in  the  rectum  to  press  the  deflected  fragment 
back  into  place,  care  being  used  not  to  injure  the  soft  parts. 

The  patient  should  keep  quiet  in  the  horizontal  position  for 
a  few  weeks,  to  allow  the  healing  process  to  consolidate  the 
fragments.  The  bowels  should  be  kept  in  a  soluble  state 
during  the  treatment,  to  prevent  accumulations  of  gas  and 
stercoracious  matter  near  the  seat  of  the  injury.  Hamilton 
recommends  that  the  bowels  be  kept  constipated  in  order  that 
the  accumulation  of  hardened  material  in  the  rectum  may 
press  back  into  line  the  displaced  fragment,  and  act  as  a  splint 
on  the  inner  surface  of  the  bone.  The  suggestion  is  quite  in- 
genious, but  the  practical  working  of  the  plan  is  questionable. 

FRACTURE   OF   THE   COCCYX. 

A  fracture  of  the  cornua  of  the  coccyx,  and  a  partial  dis- 
location of  the  bone  inwards,  constitute  an  injury,  which  is 
caused  by  a  direct  blow,  kick,  or  other  violence  telling  upon 
the  bony  appendage.  The  lesion  has  been  reported  as  occur- 
ring from  parturient,  efforts.  If  such  be  the  case  the  subjects 
must  have  been  sufficiently  advanced  in  life  to  have  the  bone 
consolidated  to  the  sacrum.  In  young  women  the  mobility 
of  the  coccyx  allows  the  bone  to  yield  to  forces  brought  to 
bear  upon  it  during  the  last  staii'e  of  labor. 


OF  THE  COCCYX.  169 

I  have  never  seen  but  one  case  of  a  broken  coccyx  ;  and 
this  accident  occurred  to  a  man  standing  on  the  platform  of  a 
car  as  the  train  was  suddenly  put  in  motion  by  the  engineer. 
The  point  or  angle  of  the  iron  railing  struck  the  passenger  in 
the  coccygeal  region,  and  caused  a  sickening  sensation  from 
the  severe  shock  to  the  nervous  system.  After  receiving  the 
injury  the  patient  took  a  seat  inside  the  coach,  and  although 
in  severe  pain,  and  complaining  of  a  general  uneasiness,  he 
chatted  with  a  fellow  traveler,  reaching  home  that  night. 
Before  morning  he  took  a  "  chill  ;"  and  had  his  family  physi- 
cian summoned.  He  no  longer  complained  of  distress  in  the 
region  hurt,  but  asked  to  be  relieved  of  a  sense  of  constric- 
tion in  the  bowels,  and  nausea  at  the  stomach.  Morphia  was 
administered  in  large  and  repeated  doses.  This  relieved  him 
of  the  acute  distress,  yet  lie  declared  that  there  was  some  ter- 
ribly deep  seated  disease  about  him  that  would  terminate 
fatally.  The  bowels  were  evacuated  by  the  influence  of  cathar- 
tics, and  the  bladder  at  length  had  to  be  relieved  by  catheter- 
ism.  On  the  tenth  day  after  the  injury  he  died;  and  none  of 
his  medical  and  surgical  attendants  had  suspected  the  true 
cause  of  death.  An  autopsy  was  held,  at  which  I  was  present. 
The  physician  using  the  scalpel,  remarked  that  he  should  first 
look  for  abscess  of  the  liver,  or  for  pus  in  or  about  that  organ. 
Finding  no  cause  for  death  in  the  viscera  of  the  abdomen,  and 
observing  considerable  redness  in  the  pelvic  colon,  the  peri- 
neum and  anus  were  inspected.  The  discoloration  in  that 
region  led  to  the  suspicion  that  the  difficulty  had  been  some- 
where about  the  lower  end  of  tlie  spinal  column.  The  body 
being  turned  over,  the  signs  of  decomposition  in  the  region 
of  the  coccyx  were  strikingly  apparent.  A  careful  dissection 
showed  that  the  coccygeal  horns  or  processes  were  broken, 
and  the  bone  somewhat  displaced  inwards.  The  entire  coccyx 
except  the  detached  cornua,  was  blackened,  and  bore  the  ap- 
pearance of  having  been  dead  for  many  days.  An  apparently 
trifling  injury,  which  had  not  attracted  the  attention  of  several 
physicians  in  consultation,  and  which  produced  more  general 
than  local  disturbance,  terminated  fatally.  This  case  is  not 
without  parallel.  Cloquet,  Petit,  and  other  surgical  writers 
upon  the  subject  of  fracture  and  dislocation  of  the  coccyx, 
speak  of  the  dangers  of  caries,  as  if  the  bone,  after  serious 
lesions,  was  liable  to  mortification.  Whether  anything  could 


170  .  FRACTURES. 

be  done  to  arrest  the  tendency  to  necrosis,  if  undertaken 
promptly,  is  not  demonstrated.  It  is  plainly  the  duty  of  the 
surgeon,  when  called  to  a  case  of  fracture  of  the  coccyx,  to 
overcome  any  inward  displacement  by  manipulation,  using  the 
finger  in  the  rectum ;  and  to  keep  the  patient  at  rest  by  the 
use  of  opium  suppositories  and  such  other  local  means  of  a 
quieting  or  stimulating  character,  as  would  afford  relief  and 
promote  a  restorative  action  in  a  severe  bruise  or  other  wound 
in  that  region. 

It  is  not  easy  to  diagnose  fracture  of  the  coccyx.  Pain  of 
a  severe  character  might  arise  from  shock  or  concussion,  as, 
also,  a  general  uneasiness,  on  account  of  the  constitutional 
disturbance.  With  a  finger  in  the  rectum  and  the  thumb  on 
the  coccyx,  a  great  increase  of  mobility  might  be  determined, 
as  well  as  displacement;  but  crepitation,  that  distinctive  si^n 
of  fracture,  can  not  certainly  be  obtained,  owing  to  the  broken 
surfaces  of  bone  being  small,  and  the  motion  imparted  not  of 
a  kind  likely  to  cause  rubbing  of  the  broken  parts  against  one 
another.  It  is  not  improbable  that  fracture  of  the  coccyx  has 
occasionally  passed  unobserved,  or  for  a  bruise  in  the  region 
of  the  sacrum ;  and  a  severe  concussion  in  that  part  of  the 
body  followed  by  sharp  pain  in  attempts  to  walk,  and  during 
defecation,  has  been  regarded  as  a  case  of  coccygeal  fracture. 
The  great  mobility  of  the  coccyx  in  young  subjects  might 
contribute  to  the  deception.  Fracture  arising  from  the  dis- 
placing force  of  the  child's  head  in  parturition,  is  quite  differ- 
ent in  character  from  that  produced  by  a  kick  or  fall  upon 
some  projecting  substance.  The  shock  is  much  less  when 
produced  by  the  forward  movements  of  a  child's  head.  When 
produced  by  accidental  violence  there  may  be  a  vast  excess  of 
force  over  that  actually  required  to  break  the  bone  ;  and  this 
excess  would  naturally  increase  the  dangers  of  the  case. 


CHAPTER  XXV. 
FRACTURE    OF   THE   FEMUR. 


The  length  of  the  femur  and  the  exposure  of  the  bone  to  a 
variety  of  forces,  contribute  to  its  liability  to  fracture.  The 
muscles  surrounding  the  femur  afford  a  certain  amount  of 
protection  against  external  shocks,  yet  this  shielding  influence 
is  more  than  counterbalanced  by  the  strain  the  bone  receives 
from  their  action.  The  different  fractures  to  which  the  bone 
is  subject,  and  the  complicated  appliances  recommended 
for  their  treatment,  constitute  a  series  of  topics  well  calculated 
to  overwhelm  the  student  who  first  directs  his  attention  to  this 
branch  of  surgical  study.  Unless  the  diagnosis  of  such  injuries 
be  clearly  made  out,  and  the  treatment  necessary  to  the 
accomplishment  of  good  results  be  clearly  understood,  and 
efficiently  carried  out,  the  most  lamentable  consequences  may 
be  expected.  An  imperfect  conception  of  the  nature  of  the 
accident,  or  a  "  trust-to-luck  "  management  of  the  injury,  will 
surely  lead  to  the  chagrin  and  disgrace  of  the  surgical  attend- 
ant, and  to  the  permanent  crippling  of  the  unfortunate  patient. 
!N"o  medical  practitioner  should  assume  the  responsibility  of 
treating  a  fractured  thigh,  unless  he  comprehends  what  is 
absolutely  necessary  to  insure  at  least  an  average  recovery.  A 
perfect  result  cannot  be  attained  in  all  instances,  for  the  cir- 
cumstances under  which  some  cases  have  to  be  treated  may 
thwart  the  best  directed  efforts  of  the  surgeon.  However, 
want  of  skill  is  the  most  common  cause  of  bad  recoveries. 

The  neck  of  the  femur  is  placed  at  an  oblique  angle  to  the 
shaft  of  the  bone,  and  in  old  age  it  more  nearly  approaches  a 
right  angle.  This  peculiar  conformation  in  advanced  life, 
together  with  an  increased  amount  of  cancellated  tissue  on 
the  inner  structure,  renders  the  bone  weak  at  a  point  subjected 
to  considerable  lever  power. 

(171) 


172  FRACTURES. 

The  troehanters  are  stout  processes  of  bcme,  but  the  greater 
of  the  two  being  subjected  to  direct  violence  in  falls,  and  the 
lesser  to  the  action  of  powerful  muscles,  they  may  be  discon- 
nected from  the  shaft,  or  forced  into  the  central  spongy  struc- 
tures. 

The  shaft  of  the  femur  is  very  long,  offering  forces  a  favor- 
able opportunity  to  break  it  in  pieces.  The  muscles  exert, 
great  influence  upon  a  bone  which  offers  the  advantage  of  such 
extensive  lever  power.  Indirect  forces  received  by  the  foot, 
and  transmitted  upward  to  the  great  curve  just  above  the 
middle  of  the  shaft  of  the  femur,  very  frequently  produce 
fractures  at  that  point. 

The  condyles  spread  out  into  a  broad  base  to  give  steadiness 
to  the  knee-joint,  but  they  have  so  much  spongy  structure 
within,  that  they  are  not  adapted  to  offer  powerful  resistance 
to  direct  forces.  The  resisting  power  of  a  bone  must  not  be 
reckoned  by  its  size,  for  the  middle  of  the  shaft,  which  is  the 
smallest  part  of  the  bone,  is  probably  the  strongest. 

The  causes  which  produce  fractures  of  the  thigh  are  numer- 
ous. When  the  direct  force  acts,  it  generally  happens  that 
the  limb  is  crushed  by  some  heavy  weight  falling  upon  it,  or 
by  a  loaded  wagon  passing  over  it.  When  an  indirect  force 
acts,  it  is  most  frequently  found  that  the  person  falls  from  a 
height,  with  the  thigh  in  such  a  position  that  the  bone  sna  ps  at  a 
point  remote  from  the  part  receiving  the  shock.  An  irregu- 
larity in  the  ground  sometimes  imparts  a  twist  to  the  leg  which 
may  prove  too  great  for  the  brittle  neck  of  the  lemur.  A 
person  fancying  he  is  treading  upon  level  ground,  lake-  a 
false  step  unawares,  and  the  muscles  not  being  employed  to 
resist  the  impetus,  or  to  counteract  the  accidental  twist  un- 
expectedly given  to  the  limb,  he  receives  a  fraetuiv  of  the  neck 
of  the  thigh  bone. 

FRACTURE    OF    THE    NECK   OF  THE   FEMUR. 

The  neck  of  the  thigh  bone  has  been  invested  with  unusual  in- 
terest, both  on  account  of  the  frequency  of  fracture  occurring  at 
that  pom  t^and  the  learned  discussions  that  have  taken  place  con- 
cerning the  possibility  and  probability  of  bony  union  taking 
place  here  as  in  fractures  through  other  parts  of  the  bone.  A  <j  no- 
tation from  Mr.Lonsdale  expresses  some  of  the  reasons  why  frac- 


OF   THE  FEMUR. 


173 


tures  through  the  cervix  fenioris  are  so  frequent :  "It  is  aii  acci- 
dent that  is  met  with  chiefly  in  old  people,  and  very  seldom, 
indeed,  in  young.  The  structure  of  the  bone  in  old  people 
becomes  altered,  owing  to  the  deficiency  of  the  animal  matter 
in  it,  causing  the  earthy  to  be  in  excess,  which  gives  a  brit- 
tleness  to  it,  that  does  not  exist  in  the  bones  of  young  people. 
This  part  of  the  bone  is  also  naturally  of  a  loose,  cancellated 
structure,  and  when  deprived  of  its  animal  matter,  will  become 
weak  and  ill  calculated  to  receive  any  severe  shock,  either 
from  the  weight  of  the  body,  or  from  a  blow  directly  applied 
to  the  part.  There  are  other  causes  also  which  tend  to  pro- 
duce fracture  of  this  part  of  the  bone. 

FIG.  64. 


Section  of  the  head,  neck,  and  upper  extremity  of  the  Shaft  of  the  Femur,  showing  the  inner 
cancellated  texture,  and  natural  shape  of  this  part  of  the  bone. 

The  muscles  surrounding  the  hip-joint  in  old  people  waste, 
causing  this  part  to  become  flattened,  and  to  have  compara- 
tively little  covering  upon  it ;  so  that  a  fall  upon  the  posterior 
part  of  the  hip,  which,  in  a  younger  person,  in  whom  the 
muscles  act  as  a  cushion,  might  tell  with  little  force  directly 
on  the  trochanter,  or  neck  of  the  bone,  would  in  an  old  one, 


174  FRACTURES. 

where  this  cushion  is  absent,  be  sufficient  to  produce  fracture 
In  old  people,  also,  the  whole  body  loses  its  elasticity,  all  the 
movements  are  heavier,  and  more  awkward  and  less  secure, 
so  that  falls  are  likely  to  take  place  from  trifling  causes,  with- 
out the  power  of  resisting  them ;  for  though  a  younger  per- 
son might  break  his  fall  by  the  use  of  his  arms,  or  by  the 
strength  and  activity  of  his  body  generally,  an  old  person  can 
not,  but  falls  like  a  dead  weight,  and  the  shock,  of  course, 
becomes  much  greater  than  it  otherwise  would  be.  All  these 
circumstances  taken  together  cause  this  kind  of  fracture  to  be 
much  more  frequent  in  old  than  young  people." 

Sex  has  something  to  do  with  the  frequency  of  the  fracture. 
In  women  the  pelvis  is  wider,  and  the  neck  of  the  femur  is 
longer,  arid  it  joins  the  shaft  nearer  a  right  angle  than  it  does 
in  men.  Elderly  females  are  apt  to  lose  confidence  in  their 
pedestrian  powers,  which,  so  far  as  it  go^s,  favors  fracture ; 
besides,  their  bones  and  bony  supports  are  weaker  or  less  de- 
veloped than  in  the  other  sex,  being  therefore  less  capable  of 
oftering  resistance  to  forces  acting  upon  the  skeleton.  Elderly 
persons,  if  they  fall  heavily  upon  the  trochanter,  may  sustain 
fracture  of  the  neck  of  the  femur.  This  kind  of  violence  has 
been  called  direct,  though  it  is  not  more  so  than  when  a  per- 
son, in  falling,  or  in  taking  a  false  step,  sends  a  force  from  the 
foot  up  to  the  neck  of  the  bone.  Indirect  violence,  then, 
must  be  considered  the  common  cause  of  fracture  through  the 
cervix  femoris. 

A  fracture  near  the  head  of  the  bone,  and  wholly  within 
the  capsular  ligament,  is  generally  transverse,  while  the  direc- 
tion of  the  fracture  is -likely  to  be  oblique,  if  it  be  near  the 
trochanters,  making  the  line  of  separation  partially  within 
and  partially  without  the  cavity  of  the  joint. 

It  is  quite  essential  to  understand  the  place  where  the  solu- 
tion of  continuity  exists,  for  in  a  fracture  near  the  head  of 
the  bone  ossific  union  need  not  be  expected,  but  in  a  fracture 
extending  outside  the  femoral  attachment  of  the-  capsular  lig- 
ament, bony  union  maybe  reasonably  expected,  with  a  strong, 
and  useful  limb.  It  will  generally  be  found  that  fractures 
wholly  within  the  capsular  ligament,  result  in  ligamentous 
unions ;  and  that  a  break  in  the  bone  outside  the  ligament  is 
about  sure  to  end  in  osseous  consolidation.  In  fractures  partly 
within  and  partly  without  the  ligament,  as  when  the  line  of 


OF  THE  FEMUR.  175 

separation  is  oblique,  or  irregular  in  its  course,  crossing  the 
attachment  of  the  ligament  to  the  bone,  tlie  union  is  most 
likely  to  be  osseous,  though  it  may  be  fibrous. 

Displacement  has  considerable  to  do  with  consolidation, 
though  not  so  much  as  mobility.  It'  the  separation  of  the 
broken  surfaces  be  so  great  that  there  is  scarcely  any  contact, 
bony  union  is  not  to  be  expected  ;  and  if  in  addition  to  dis- 
placement, there  be  constant  rocking  of  one  fragment  upon 
the  other,  efforts  at  consolidation  are  thwarted. 

Much  has  been  said  about  lack  of  reparative  supplies 
afforded  to  the  articular  fragment,  as  if  it  were  completely  cut 
off  from  vascular  connections,  except  through  the  ligamen- 
tum  teres.  In  some  instances,  especially  if  the  synovial  mem- 
brane be  torn,  as  it  is  likely  to  be,  the  head  of  the  bone  is 
completely  isolated  except  through  the  round  ligament.  This 
theory  in  regard  to  scanty  nutritive  supplies,  is  supported  by 
the  fact  that  large  quantities  of  reparative  bony  material  are 
deposited  around  the  end  of  the  lower  fragment,  constituting 
an  excess  of  callus,  while  the  scantiest  amount  is  accumulated 
about  the  end  of  the  short  or  upper  fragment.  The  symptoms 
of  a  fracture  within  the  capsule  are,  shortening  of  the  limb, 
aversion  of  the  foot,  motion  between  the  fractured  portions 
of  the  bone,  crepitus,  great  pain  about  the  joint,  and  inability 
to  move  the  limb,  or  to  bear  the  weight  of  the  body  upon  it. 
The  shortening  is  not  marked  directly  after  the  reception  of 
the  fracture,  but  it  increases  from  day  to  day  till  it  reaches  an 
inch  or  more  The  shortening  may  be  overcome  by  making 
extension,  and  as  soon  as  this  force  is  relaxed,  the  limb  draws 
up  again.  It  requires  considerable  care,  and  regard  for  accu- 
racy, to  ascertain  whether  one  leg  be  longer  than  the  other. 
A  limb  is  often  supposed  to  be  shorter  than  the  other,  when 
the  position  of  the  patient's  body  produces  the  deception. 
Anybody  can  lie  upon  the  back,  ancl  so  twist  the  pelvis  as  to 
make  one  leg  appear  of  a  different  length  from  the  other. 
In  the  examination  of  a  patient  to  ascertain  the  relative 
length  of  the  limbs,  the  pelvis  must  be  placed  straight  with 
regard  to  the  transverse  diameter  of  the  body ;  for  any  obli- 
quity in  this  direction  will  give  a  corresponding  obliquity  to 
the  lower  extremities,  and  cause  one  to  appear  longer  than 
the  other.  The  pelvis  being  quite  straight,  the  two  kncc-.s 
ought  to  correspond,  and  the  two  heels  also,  if  both  limbs  are 


176  FRACTURES. 

of  the  same  length.  After  observations  have  been  taken,  with 
the  body  carefully  arranged  as  just  indicated,  measurements 
should  be  taken  to  determine  exactly  the  amount  of  shorten- 
ing, if  any  exist.  The  patient  being  placed  in  bed,  and  care 
taken  that  the  shoulders'and  pelvis  are  parallel  to  one  another, 
and  the  legs  in  conformity  to  the  straight  attitude,  a  piece  of 
tape  or  inelastic  cord  is  made  to  take  the  distance  from  the 
anterior  superior  spinous  process  of  the  ilium  to  the  patella 
or  external  malleolus  ;  or,  what  is  better,  from  the  symph  ysis 
pubis  to  the  internal  malleolus  of  each  ankle.  Any  well  de- 
fined and  unvarying  point  in  the  body  is  as  good  as  those  in- 
dicated ;  the  upper  or  lower  extremity  of  the  sternum,  or  the 
umbilicus,  will  answer  as  a  point  to  commence  the  measure- 
ment. As  the  patella  is  rather  moveable,  it  will  be  necessary 
to  measure  to  the  lower  point  of  the  bone  when  it  is  pulled 
upwards,  in  order  to  arrive  at  accuracy.  Shortening  alone  is 
not  a  sure  indication  of  fracture,  for  the  limb  may  have  been 
shrunken  from  childhood,  or  drawn  up  from  dislocation,  but 
in  connection  with  other  signs,  this  becomes  valuable.  In  rare 
instances  there  may  be  fracture  and  no  displacement,  or 
shortening.  Mr.  Stanley  relates  the  following  case,  wh'u-h 
illustrates  the  point.  "  A  man  aged  sixty,  was  knocked  down 
in  the  street ;  he  complained  of  pain  in  the  hip,  but  there  was 
neither  shortening  nor  eversion  of  the  limb,  and  its  several 
motions  could  be  executed  with  perfect  freedom  and  power. 
A  fracture  was  not  suspected  ;  the  patient,  therefore,  was 
merely  confined  to  his  bed.  In  the  fifth  week  from  the  date 
of  the  accident  he  died  from  another  cause.  Xo  trace  of  in- 
jury was  found  in  the  parts  around  the  hip  joint,  but  small 
effusions  of  blood,  apparently  not  recent,  w^ere  discovered  be- 
neath the  synovial  and  fibrous  membrane,  covering  the  neck 
of  the  femur,  also  beneath  the  synovial  membrane  covering 
the  ligamentum  teres.  The  head  and  neck  of  the  bone  were 
sawed  through  their  middle,  and  in  each  portion  a  dark  line, 
evidently  occasioned  by  the  effusion  of  blood,  was  seen  ex- 
tending through- the  bone  at  the  base  of  the  neck.  A  fracture 
was  discovered  extending  along  this  line ;  but  the  broken  sur- 
faces were  in  contact,  and  the  &ynovial  and  fibrous  membrane 
covering  the  neck  of  the  bone  was  uninjured."  "  In  this  case," 
Mr.  Stanley  very  pertinently  remarks,  "  if  an  attempt  had 
been  made  to  walk  at  the  end  of  two  or  even  three  weeks 


OF  TJIK  FEMUR.  177 

from  the  accident,  a  separation  of  the  fractured  surfaces,  and 
consequent  shortening  of  the  limb,  would  have  been  the 
result." 

Either  from  the  natural  inclination  of  the  foot  to  gravitate 
outwards,  or  from  the  action  of  the  rotator  muscles,  the  foot, 
after  fracture  of  the  cervix  lemoris,  is  almost  always  found  to 
be  in  a  state  of  aversion.  In  extremely  rare  instances,  mostly 
where  the  force  producing  the  fracture  violently  twists  the 
foot  inwards,  the  limb  may  continue  in  that  position.  It  is 
highly  probable  that  /////></<•/%//  has  considerable  to  do  with  the 
position  of  the  limb  in  eases  varying  essentially  from  the 
usual  attitude  assumed  after  fracture  of  the  neck  of  the  thigh 
bone.  The  fragments  may  be  interlocked,  or  the  lower  one 
may  be  driven  through  the  capsular  ligament,  and  held  in  an 
inverted  position  until  extension  frees  one  or  both  pieces  from 
the  entangled  state.  If  the  limb  be  somewhat  li.<'f<l  in  an 
everted  or  an  inverted  position,  there  exists  a  mechanical  ob- 
stacle to  rotation  either  in  one  direction  or  the  other. 

When  crepitation  can  be  produced  by  motion  imparted  to 
the  limb,  it  is  conclusive  of  fracture;  but  in  many  instances 
this  decisive  and  distinctive  sign  can  not  be  produced.  The 
round  bead  of  the  bone  and  its  free  motion  in' the  acetabulum 
require  the  least  interlocking  of  the  fractured  surfaces  to  cause 
the  lesser  fragment  to  follow  the  natural  movements  of  the 
larger  The  articular  fragment  is  so  nearly  concealed  in  the 
cotyloid  cavity  that  it  can  not  be  seized  and  held  fast  while 
the  other  is  made  to  grate  against  it.  Crepitus  can  be  elicited 
in  nearly  every  instance  of  fracture  of  the  neck  of  the  femur, 
if  the  lower  fragment  be  forcibly  extended  and  carried  through 
all  the  motions  possible  for  the  limb  to  take,  yet  a  rash  course, 
simply  to  produce  crepitation,  would  not  be  justifiable.  There 
are  plenty  of  points  to  decide  the  question  of  fracture,  even 
it'  crepitus  be  not  sought. 

It  is  not  a  little  singular  that  a  patient  with  a  broken  thigh 
bone  can  walk  directly  after  receiving  the  injury.  As  a  gen- 
eral thing  the  patient  falls  immediately  upon  the  reception  of 
the  fracture  ;  or,  having  received  the  fracture  by  the  fall,  he 
is  unable  to  rise  ;  yet  there  are  notable  instances  in  which 
patients  have  not  only  risen  from  the  ground,  but  walked 
almost  as  if  nothing  serious  had  happened.  These  unusual 
powers  after  fracture,  are  difficult  to  be  understood.  Theo- 
12 


178  FKACTURKS. 

rists  have  attempted  to  explain  them  on  the  supposition  of  a 
firm  irapaction,  and  on  the  ground  that  the  fragments  were 
interlocked.  It  has  also  been  claimed  that  in  such  cases  the 
untorn  periosteum  holds  the  pieces  in  exact  apposition. 
Usually  the  loss  of  voluntary  power  is  complete,  and  the  limb 
falls  into  a  state  of  eversiou  characteristic  of  the  injury. 

Any  one  familiar  with  all  the  peculiarities  of  the  limb  after 
fracture  of  the  cervix  femoris,  has  observed  the  change  of 
position  assumed  by  the  great  trochanter.  In  the  event  o: 
shortening,  the  bony  prominence  is  drawn  upwards,  so  that  ii 
occupies  a  site  nearer  the  ilium ;  eversion  throws  it  back- 
wards;  and  impaction,  when  it  exists,  carries  the  pr< 
closer  to  the  acetabulum,  giving  the  limb  a  flattened  appear- 
ance not  seen  in  the  sound  thigh.  Another  notable  feature 
of  the  trochanter  is,  that  in  rotating  the  limb  the  bony  pro- 
tuberance does  not  describe  the  segment  of  so  large  a  circle 
as  it  does  in  its  natural  state. 

PAIN  AND  SWELLING. — There  is  rarely  much  pain  in  what  is 
called  intra-capsular  fracture,  unless  the  limb  be  moved  or 
disturbed  by  manipulation.  Gently  extended  and  propped 
up  on  each  side,  the  broken  limb  is  affected  with  little  or  no 
distress.  However,  any  efforts  to  voluntarily  move  the  limb, 
or  any  attempts  to  discover  the  nature  of  the  injury  by  rude 
handling,  are  attended  with  severe  pain.  The  swelling  may 
be  moderate,  especially  if  no  violence  be  done  to  the  parts  in- 
volved, except  mere  fracture. 

In  many  cases  the  normal  size  of  the  limb  renders  manipu- 
lation at  the  seat  of  injury  quite  useless  ;  the  diagnosis,  there- 
fore, is  based  more  upon  measurements,  eversion,  and  other 
signs  already  indicated,  than  upon  the  senseless  kneading  that 
inexperienced  practitioners  are  apt  to  apply  directly  to  the 
parts  about  the  hip  joint  suspected  of  fracture.  If  each  diag- 
nostic symptom  be  carefully  considered,  enough  signs  will  be 
discovered  to  decide  almost  any  case,  though  some  signs  of 
fracture  may  not  be  prominent.  Generally  it  requires  only  a 
superficial  examination  to  determine  the  nature  of  the  injury; 
in  rare  cases  the  closest  scrutiny  is  demanded  to  decide  the 
matter.  It  is  quite  essential  that  the  evidence  of  fracture  be 
ascertained  when  it  exists,  in  order  that  the  treatment  may 
be  well  directed.  To  confine  a  patient,  hampered  with  frac- 
ture dressings,  to  the  horizontal  position  for  weeks  and 


OF  THE  CERVIX  FEMORIS. 


179 


months,  under  the  supposition  that  a  fracture  exists  when 
really  it  does  not,  would  be  quite  unpardonable. 


FIG.  65. 


FRACTURE    OF    THE    CERVIX    FEMORIS    WITHIN 
THE    CAPSULE. 

In  a  recent  fracture  of  the  neck  of  the  femur  within  the 
capsule,  the  tissues  immediately  involved  are  reddened,  and 
there  is  an  abundant  effusion  of  lymph,  and  not  much  extrava- 
sation of  blood.  The  capsu- 
lar  ligament  may  preserve  its 
integrity,  and,  also,  the  syno- 
vial  membrane ;  these  struc- 
tures, however,are  quite  likely 
to  be  lacerated,  especially  the 
delicate  coverings  of  the  bone 
at  the  seat  of  fracture.  In 
the  course  of  a  few  days  the 
presence  of  ivparative  mate- 
rial is  discoverable,  and  osse- 
ous particles  at  length  find 
their  way  to  the  borders  of 
the  fractured  surfaces ;  yet 
before  any  bony  matter  is  ex- 
uded, plastic  lymph,  floating 
in  an  abundance  of  synovia! 
fluid  and  gathered  in  shreds 
to  the  torn  tissues,  shows  a  disposition  to  connect  the  frag- 
ments with  fibrous  bands. 

In  old  cases,  the  capsular  ligament  becomes  thickened,  es- 
pecially at  its  upper  part,  which  has  to  sustain  the  weight  of 
the  body  in  walking,  the  long  fragment  pressing  up  against  it 
for  support  at  every  step.  In  cases  where  no  impaction  exists, 
and  no  real  progress  is  made  towards  osseous  consolidation,  a 
variety  of  conditions  are  found  within  the  capsule  of  the 
joint ;  in  some  cases  the  organized  bands  of  plastic  material 
form  a  pretty  firm  connection  between  the  fragments,  the 
patient  being  able  to  walk  with  some  assistance  from  cane  or 
crutch ;  in  other  instances  the  fibro-ligarnentous  bands  are 
slender  or  too  long  to  be  of  any  service  as  connecting  media 
between  the  fragments  ;  finally,  the  fractured  surfaces  may 


Fracture  of  the  cervix  femoris  within  the 
capsule. 


180 


FRACTURES. 


FIG.  66. 


mutually  yield  to  one  another,  the  short  fragment  becoming 
excavated  and  polished,  and  the  cervical  portion  of  the  long- 
piece  rounded  into  a  conical  knob  to  fit  into  the  cup-like  cav- 
ity presented  to  it.  Such  a  false  joint  would  be  a  troublesome 
aftair,  yet  not  necessarily  prevent  the  person  from  enjoy  ing- 
somewhat  restricted  locomotion.  Absorption  occasionally 
alters  the  broken  parts  in  a  wonderful  manner.  The  short 
piece  has  been  completely  removed  by  the  absorptive  processes, 
and  the  upper  end  of  the  long  fragment  has  been  dissolved 
and  removed,  the  absorption  reaching  into  the  greater  tro- 
chanter,  leaving  nothing  but  the  shaft  of  the  bone  which  was 
steadied  in  place  by  the  muscles  inserted  into  it,  and  by  the 
condensed  tissue  surrounding  it.  In  the  event  of  impaction, 
the  cervical  portion  of  the  long  fragment  being  driven  into 
the  cancellated  structure  of  the  head  of  the  bone,  the  connec- 
tion is  so  intimate  that  the  pieces 
mutually  steady  each  other,  and 
favor  bony  consolidation. 

A  great  deal  of  interest  attaches, 
at  the  present  time,  to  the  ques- 
tion whether  bony  union  ever 
follows  fracture  of  the  cervix 
femoris,  the  line  of  separation 
being  wholly  within  the  capsule. 
It  is  pretty  generally  admitted 
among  surgeons  who  have 
studied  pathological  specimens, 
that  such  a  fracture,  if  impacted, 
may  result  in  consolidation  ;  but 
if  the  break  be  simple,  entirely 
within  the  capsule,  and  uncom- 
plicated with  impactiou,  or  tear- 
ing of  the  capsular  ligament,  the 

Consolidation  followingTmpaction.         union    \s    most    likely  to    1)0  liga- 

mentous  and  imperfect  at  that.  Much  ingenuity  has  be-on 
displayed  in  attempting  to  account  for  the  lack  of  bony 
union  ;  the  fact  that  motion  between  the  fragments  can  not 
be  arrested  by  any  ordinary  apparatus,  has  some  bearing  on 
the  question;  the  abundance  of  synovia  secreted  under  the 
influence  of  prolonged  irritation,  diluting  and  otherwise  im- 
pairing the  qualities  of  the  reparative  materials,  is  adverse  to 


OF  THE  CERVIX  FEMORIS. 


181 


1-V;.  67. 


consolidation  of  the  fracture  ;  bnt  the  chief  obstacle  to  repair 
seems  to  reside  in  the  almost  complete  isolation  from  vessels 
and  nerves,  to  which  the  head  of  the  bone  and  remnant  of 
the  neck  are  subjected  by  the  fracture.  The  ligamcntum  teres 
is  a  small  band  of  dense  white  tissue,  with  scarcely  a  vascular 

sign  in  it.  An  adequate  sup- 
ply of  reparative  material 
could  not  be  expected  to  find 
its  way  through  such  attenu- 
ated channels.  If  the  frag- 
ments could  be  maintained  in 
perfect  apposition  for  a  few 
days  it  is  possible  that  a  direct 
union,  similar  to  what  is 
known  as  "Hist  intention" 
in  wounds  of  the  soft  tissues, 
might  occasionally  take  place, 
which  might  in  time  ensure 
osseous  consolidation.  In 
some  of  those  rare  instances 
in  which  early  union  is  known 

Ligamentous  union  following  fracture  of  the     to  have  taken  phlCC    after    ill- 
neck  of  the  femur  within  the  capsule.  ,  .    , 

tracapsular  fracture,  without 

impaction,  it  is  probable  that  the  results  followed  perfect  co- 
aptation,  freedom  from  motion,  and  the  cpiick  restoration  of 
the  usual  channels  of  supply. 

Where  the  line  of  separation  is  [tartly  within  and  partly 
without  the  capsule,  giving  the  otherwise  isolated  fragment  an 
opportunity  to  get  its  supplies  without  drawing  for  them 
through  the  round  ligament,  the  chances  in  favor  of  bony 
union  are  greatly  increased. 


EXTRA-CAPSULAR 


FRACTURE 
FEMORIS. 


OF     THE    CERVIX 


In  extra-capsular  fractures,  /.  r.,  where  the  line  of  separation 
is  entirely  outside  the  apparatus  of  the  joint,  the  upper  frag- 
ment having  a  good  supply  of  vessels  entering  it  l>y  ihe  many 
foramina  so  conspicuous  in  that  part  of  the  bone,  the  union 
is  likely  to  be  osseous.  Even  if  the  line  of  fracture  extend 
slightly  beyond  or  within  the  capsule,  it  does  not  seem  to  in- 


182 


FRACTURES. 


FIG.  68. 


terfere  with  consolidation  in  cases  where  the  greater  part  of 
the  fracture  exists  in  the  trochanter  and  that  part  of  the  neck 
immediately  adjoining  it.  It  is  not  uncommon,  in  falls  upon 
the  trochanter,  for  the  fractured  cervix  to  penetrate  the  can- 
cellated structure  of  that  great  process  of  bone,  and  even  to 
act  the  part  of  a  wedge  and  split  it.  Sometimes  the  two  tro- 
chanters  are  rent  asunder  by  this  wedge  force,  more  or  less 
impaction  taking  place  in  every  instance.  Specimens  are  in 
existence  which  show  the  line  of  separation  to  be  through  the 
trochanter  major,  the  upper  part  remaining  with  the  neck  of 
the  femur,  and  the  lower  with  the  shaft  of  the  bone.  In  a 
greater  number  of  cases,  however,  the  fracture  is  multiple  or 
comminuted,  the  trochanter  being  broken  into  several  frag- 

ments, and  the  cervix  femoris  de- 
tached from  all  of  them. 

Although  bony  union  is  the  rule, 
in  extra-capsnlar  fractures,  the 
healing  process  is  slow,  and  the 
consolidation  of  the  cervix  to  the 
trochanteric  fragments  is  more 
tardy  than  it  is  in  fractures  lower 
down.  A  notable  feature  con- 
nected with  consolidation  of  frac- 
tures near  the  hip-joint  is  the  gival 
exuberance  of  ossific  deposits, 
which  interfere  with  the  motions 
of  the  limb,  and  tend  to  deceive 
any  one  examining  the  parts  with 
the  object  of  ascertaining  the  orig- 

Exoeas  of  callus  after  extracapsular    •       -i  C4.ot~  „*•  4-l.p  iniiii-v 
fracture  of  the  femur.  lliai  State  (  eillJUM. 


Rough  points  in  the  reparative  material  render  muscular 
movements  painful  ;  and  may  inflict  permanent  hum-ness  upon 
the  patient.  These  ledges  of  bone  may  become  rounded  oil' 
in  time,  yet  their  complete  obliteration  need  not  be  expected. 

The  symptoms  of  extra-capsular  fracture  very  closely  re- 
semble those  manifested  by  fracture  within  the  capsule:  there 
is  shortening,  eversion,  inability  to  move  the  limb,  and  the 
other  signs  peculiar  to  fractures  in  general.  If  the  great  tro- 
chanter be  involved  in  the  fracture,  the  mobility  of  the  frag- 
ments, and  the  attending  crepitns,  would  be  distinctive  of 
extra-capsular  lesion.  In  the  extra-capsnlar  variety  the 


OF  THE  CERVIX  FEMOIUS.  183 

shortening  of  the  limb  is  immediately  to  the  extent  of  an  inch 
or  more,  while  in  the  other  variety  the  shortening  rarely 
reaches  its  maximum  for  several  days. 

The  accidents  which  are  most  liable  to  be  confounded  with 
fractures  of  the  neck  of  the  femur,  are  dislocations  of  the 
head  of  the  femur  upon  the  pubes,  severe  contusions  of  the 
hip,  paralysis,  and  absorption  of  the  neck  of  the  thigh  bone 
from  chronic  arthritis.  A  fracture  of  the  acetabular  cavity, 
the  bottom  being  driven  into  the  pelvis,  the  head  of  the  femur 
following,  may  present  features  leading  to  the  suspicion  that 
the  cervix  femoris  is  broken.  However,  a  critical  considera- 
tion of  each  symptom,  and  a  careful  analysis  of  each  group  of 
signs,  will  lead  to  a  rational  solution  of  almost  every  case. 
If  the  surgeon  is  not  able  to  determine  the  exact  course  of 
the  fracture  in  every  case  it  is  practically  of  very  little  impor- 
tance, for  the  treatment  is  substantially  the  same  for  all  frac- 
tures in  the  vicinity  of  the  joint.  The  real  nature  of  obscure 
cases  can  only  be  determined  after  death.  Very  few  suits,  for 
alleged  malpractice,  have  grown  out  of  imperfect  recoveries 
after  fractures  of  the  neck  of  the  femur,  for  the  reason  that 
even  the  most  experienced  surgeons  are  averse  to  giving  a 
positive  opinion  in  regard  to  obscure  injuries  about  the  hip 
joint.  In  a  recent  case  of  severe  injury  in  the  vicinity  of  the 
hip  joint,  where  great  pain  and  swelling  are  in  the  way  of  u 
satisfactory  examination,  it  is  best  to  put  the  patient  under 
the  influence  of  chloroform,  when  a  more  thorough  explora- 
tion can  be  carried  on. 

Some  very  interesting  specimens  of  defective  and  deformed 
femurs  are  in  existence,  which  have  been  selected  and  pre- 
served to  show  that  bony  union  will  take  place  after  intra- 
capsular  fracture.  Sir  Astley  Cooper  had  gained  the  reputa- 
tion of  having  taught  that  ossin'c  union  could  never  take  place 
if  the  line  of  fracture  was  wholly  within  the  capsule.  Certain 
other  surgeons  took  a  different  view  of  the  question,  and 
hunted  the  museums  and  graveyards  for  thigh  bones  which 
tended  to  disprove  the  teachings  accredited  to  Mr.  Cooper. 
The  specimens  were  sawed  through  and  through  in  order  to 
display  the  white  line  of  ivory  hardness  that  seemed  to  mark 
the  consolidation  of  the  fragments.  Many  of  the  specimens 
supposed  to  represent  the  line  of  union,  were  cast  aside  as 
spurious,  and  as  representing  the  effects  of  chronic  arthritis, 


184 


FRACT  LIKES. 


or  fracture  partly  outside  the  cnpsular  ligament.  The  numer- 
ous specimens  were  narrowed  down  hy  professional  criticism 
to  a  half  dozen,  more  or  less,  of  bones  that  furnish  evidence 
of  having  been  broken  within  the  capsule,  and  afterwards 
consolidated.  The  late  Prof.  K.  I).  Muss.y  obtained  a  few 
pathological  specimens  of  the  thigh  bones,  which  offered 
quite  convincing  proof  of  having  been  fractured  within  the 
capsule,  and  of  osseous  union  following  the  injuries.  These 
specimens  were  taken  to  Europe  and  exhibited  to  distinguished 
surgeons  there  for  the  purpose  of  eliciting  opinions  concerning 
the  evidence  of  fracture  and  subsequent  consolidation.  It  is 
a  verity  that  "  doctors  disagree,"  and  in  regard  to  the  morbid 
marks  borne  by  the  bones  in  question,  there  was  not  a  unitv 
of  opinion.  Of  one  specimen  which  had  been  regarded  as 
clearly  indicating  the  line  of  osseous  union  after  fracture 
within  the  capsule,  Mr.  Cooper  said  there  never  had  been 
any  fracture  in  the  case,  or,  if  there  had.  the  line  of  separation 
had  run  outside  the capsular  ligament,  Mr.  John  Thoinpx'ii. 
of  Edinburgh,  declared  "  upon  his  truth  and  honor"  that  a 
fracture  had  never  existed  in  the  specimen,  but  the  changes  in 

the  shape  and  appearances  of 
the  bone  were  due  to  chronic 
inflammatory  action  and  ab- 
sorption. Other  pathologists 
abroad  believed  that  the  bone 
had  been  fractured.  American 
surgeons  who  have  examined 
the  specimens  generally  nirn-e 
in  the  opinion  that  intra-cap- 
sular  fracture  once  existed  in 
them.  There  is  also  a  specimen 
of  the  same  kind  in  the  Wistar 
and  Horner  Museum  of  "Phila- 
delphia, and  one  belonging  to 
Prof.  Willard  Parker,  of  New 
_^  York.  Prof.  II.  II.  Smith,  of 

Bony  onion  after  intra-capsular  fracture ;—    Philadelphia,    thinks    that    Dr. 
with  evidence  ol  nnpaction.  .  , 

Parkers     specimen    does    not 

bear  positive  evidence  of  fracture  ;  or,  if  a  line  of  sepa ration 
did  exist,  it  must  have  been  partly  extra-capsular.  In  a 
specimen  of  mine,  exhibited  by  figure  <J9,  the  primary  frac- 


Fia.  69. 


OF  THI;  <;KI:ATKU  TROCHANTER. 


I  •-> 


ture  was  undoubtedly  intra-capsular,  but  impaction  must  have 
taken  place,  as  indicated  by  the  disturbance  of  the  cancellated 
structure  of  the  trot-haulers.  As  hel'ore  stated,  the  impaction 
of  the  fragments  favors  consolidation  in  a  variety  of  ways, 
therefore  such  specimens  are  not  legitimate  evidence  in  settling 
the  question  of  osseous  union  after  simple,  uncomplicated  iu- 
tra-capsnlar  fracture. 


FIG.  70. 


Fracture  of  the  ex- 
tremity of  the 
greater  trot-banter. 


FRACTURES    OF    TIIK    (HtKATKK   TROCHANTKI!. 

Fracture  of  the  trochanter  major,  uncomplicated  with  frac- 
tures of  the  neck  or  shaft  of  the  femur,  is  an  extremely  rare 
accident.  Only  a  tew  cases  have  fallen  under  the  notice  of 
surgeons,  and  some  of  these  were  not  discov- 
ered or  verified  until  after  death.  The  accom- 
panying- diagram  represents  a  simple  fracture 
of  the  process,  uncomplicated  with  more  ex- 
tensive lesions  of  the  hone. 

A  splitting  of  the  troehanter  which  is  pro- 
duced hy  impaction  in  connection  with  fracture 
of  the  cervix  femoris,  is  more  properly  consid- 
ered as  a  part  of  the  injury  to  the  neck  of  the 
bone. 

Heavy    falls   upon  the  hip  may   produ< 
FIG.  71.  chipping  off  of  the   the  tip  of  the 

trochanter,  to  a  greater  or  less 
depth;  and  age  has  not  so  much  to 
do  with  the  injury  as  it  has  witli 
fractures  of  the  cervix  femoris.  The 
break  is  not  always  characterized  hy 
displacement,  for  the  fibrous  struc- 
ture covering  the  process  may  con- 
tinue untorn,  and  hold  the  fragment 
in  place.  If  the  enveloping  fibrous 
tissue  be  lacerated  the  fragment  will 
be  drawn  some  distance  away  from 
the  rest  of  the  bone,  by  the  muscle- 

Comminuted  fracture  of  the  cervix    inserted    into  it.        Ill  SUcll   a   case  the 
lemons  and  of  the  trochanter  major. 

detached  fragment  could  be  felt  in 

its  mobile  state,  though  it  would  be  difficult  to  bring  it  in 
contact  with  the  other  fragment  unless  the  limb,  carried  into 


186  FRACTUUKS. 

extreme  abduction,  sufficiently  favored  apposition  to  allow  of 
contact.  Once  brought  into  place  the  piece  might  be  rubbed 
against  the  broken  surface  it  originally  left,  and  be  made  to 
produce  crepitus. 

The  exposed  position  of  the  great  trochanter  leads  to  the 
conclusion  that  the  process  might  be  frequently  broken,  but 
experience  does  not  sustain  the  inference.  Probably,  if  the 
neck  of  the  femur  could  better  maintain  its  integrity  under 
severe  shocks,  the  trochanter  would  be  the  more  frequently 
broken.  As  it  is,  the  yielding  of  more  fragile  parts,  saves  the 
trochanter. 

._      ,.,,  In   the    event    of   fracture,  separating   the 

greater  part  of  the  process,  the  pain,  swelling, 
and  deformity  might  lead  to  the  supposition 
that  some  more  important  lesion  had  been  sus- 
tained, therefore  a  careful  diagnosis  should  be 
entered  into  before  a  conclusion  is  drawn.     A 
patient  with  a  broken  trochanter  might  not  lie 
fortunate  enough  to  secure  bony  union,  though 
ctanter°major.r°"     the  detached  fragment  be  kept  at  rest,  and  in 
a  state  of  partial  apposition.     The  horizontal 
attitude  of  the  body,  with  the  fragment  drawn  downwards  by 
means  of  adhesive  strips  applied  while  the  leg  is  abducted,  i.- 
about  all  that  can  be  done  to  secure  a  favorable  result. 


TREATMENT  OF  FRACTURES  OF  THE  NECK  OF 
THE  FEMUR. 

Substantially  the  same  kind  of  treatment  is  indicated  for  all 
kinds  of  fractures  about  the  neck  of  the  femur,  whether  the 
line  of  separation  be  intra  or  extra-capsnlar,  or  partly  within 
and  partly  without  the  capsule,  including  impaction  and  split- 
ting of  the  greater  trochanter.  The  points  to  be  overcome  are 
shortening,  eversion,  and  mobility.  The  object  to  be  gained 
in  intra-capsnlar  fracture  is  a  short  and  firm  ligamentous 
union,  and  if  consolidation  incidentally  incline  to  take  place, 
it  should  be  favored  by  the  treatment ;  in  cxtra-eapsular  frac- 
ture osseous  union  may  be  reasonably  expected,  and  proper 
dressings  favor  the  desired  result.  However,  the  kind  of 
patients  liable  to  fracture  of  the  neck  of  the  femur  is  such, 
that  confinement  to  the  hori/.ontal  position,  and  the  irritation 


OF  THE  NECK  OF  THE  FEMUR.  187 

produced  by  dressings,  are  not  borne  without  complaint  and 
opposition.  Some  old  people  are  so  restive  under  the  restraint 
of  fracture  dressings  that  they  will  assume  the  responsibility 
of  throwing  them  all  off.  I  well  remember,  in  my  professional 
beginnings,  of  having  spent  an  hour  or  two  in  dressing  an 
old  man's  thigh  who  had  broken  his  cervix  femoris  by  step- 
ping on  his  grandchild's  playthings.  I  congratulated  myself 
upon  the  success  of  having  dressed  the  limb  so  skillfully.  The 
next  morning  I  called  to  see  how  my  surgical  case  progressed, 
not  doubting  but  all  was  right.  My  patient  appeared  at  ease 
and  composed.  Upon  asking  him  how  the  leg  was  doing,  he 
said,  "  I  could  not  endure  your  traps  an  hour,  so  I  threw  them 
aside,  and  put  in  practice  my  own  plan,  which  you  can  inspect 
but  not  interfere  with."  The  apparatus  for  producing  exten- 
sion and  counter-extension,  with  all  additional  straps,  and 
trappings,  were  gone,  and  the  patient  had  placed  the  tendo- 
Achillis  of  the  fractured  limb  between  the  toes  of  the  sound 
foot;  and  thus  he  produced  moderate  extension,  prevented 
eversion,  and  maintained  the  limb  in  a  state  of  ease.  He  ab- 
solutely refused  to  have  any  dressings  applied  to  the  limb,  and 
kept  up  his  novel  plan  of  treatment  quite  steadily  for  weeks. 
He  at  length  got  up  with  a  useful  limb,  consolidation  having 
taken  place,  though  there  was  shortening  to  the  extent  of  an 
inch  or  more,  and  much  stiffness  about  the  hip-joint,  owing 
in  part  to  an  excess  of  callus,  or  "  buttress  of  bone,"  thrown 
out  near  the  trochanteric  lines. 

Experience  teaches  that  a  great  amount  of  extension  should 
not  be  made  even  if  the  shortening  be  not  entirely  overcome  ; 
first,  because  patients  can  not  endure  the  forces  applied;  and, 
second,  because  the  fragments  are  found  not  to  rest  in  apposi- 
tion if  subjected  to  much  traction.  The  eversion  can  be  easily 
overcome  by  the  judicious  use  of  sand  bags  or  other  easily 
pressing  props. 

The  long  splint,  so  called,  which  reaches  from  the  foot  to 
near  the  armpit,  or  the  long  double  splint,  extending  from  the 
axillae  down  on  each  side  of  the  body  and  along  the  outsides 
of  the  legs  to  a  foot-piece,  requiring  perinea!  bands  to  secure 
counter-extension,  is  painful  to  wear,  even  insupportable  in 
many  instances. 

A  wide  belt  of  cloth  buckled  around  the  hips,  with  a  notch 
near  the  anus  to  facilitate  evacuations,  serves  a  good  purpose 


188 


FRACTURES. 


in  steadying  the  broken  cervix,  especially  it'  the  patient  be 
placed  on  a  firm  mattress,  with  the  knee  moderately  fluxed 
over  a  large  sand  bag.  This  arrangement  can  be  made  still 
more  complete  by  strapping  the  lower  part  of  the  thigh  or  the 
ankle  to  the  foot  of  the  bed,  raising  the  posts  a  little  by  put- 
ting bricks  under  them,  to  give  the  patient's  body  a  slight  in- 
clination toward  the  head  of  the  bed.  I  have  treated  patients 
in  this  way  quite  comfortably  for  them  and  satisfactorily  to 
myself.  The  "  wire  breeches"  figure  10,  fill  the  most  indiea- 

FIG.  7:;. 


The  "  wire  breeches  "  ji 


tioris  of  any  species  of  apparatus  yet  invented  for  the  treat- 
ment of  fractures  through  the  cervix  femoris.  It  >honld  be 
well  padded  to  obviate  excoriations,  and  made  so  nearly  to  fit 
the  body  and  limbs  as  to  be  comfortable.  Extension  is  made 
from  the  foot-piece,  and  counter-extension  against  the  tuberosi- 
ties  of  the  ischium.  The  apparatus  allows  the  patient  to  be 
bolstered  up  in  bed,  without  imparting  much  motion  to  the 
fragments;  and  it  has  an  opening  left  between  the  leg  pieces 
for  evacuations  of  the  bowels  to  pass.  I  have  used  the  ••  wire 
breeches"  in  two  or  three  cases,  and  secured  the  happiest 
re-  ults. 

Cases  are  reported  as  having  been  successfully  treated  l»y 
placing  the  limb  over  a  double  inclined  plane  made  of  pillows 
or  junk.  This  is  an  easy  attitude,  and  the  plan  is  so  simple 
that  it  may  be  readily  put  in  practice  under  nlmost  any  circum- 
stances. The  inexperienced  practitioner  is  apt  to  think,  be- 
cause fracture  of  the  neck  of  the  femur  is  a  serious  lesion,  that 
a  complicated  apparatus  is  demanded  for  its  treatment.  The 


OF  THE  XECK  OF  THE  FEMUR.  189 

quicker  lie  dismisses  such  an  idea  the  better  it  will  be  for  him- 
self and  patient.  heath  has  ensued  from  the  confinement  of 
feeble  and  aged  persons  in  a  too  rigid  and  -scientific  appara- 
tus." If  a  patient  docs  not  bear  the  straight  splint  or  any 
other,  without  becoming  exhausted  by  the  restraint  and  hori- 
zontal position,  all  dressings  >honldbe  laid  aside,  and  attention 
paid  to  comfort  and  general  recuperation.  Xo  particular  kind 
of  dressing,  then,  can  be  carried  out  in  all  cases.  The  surgeon 
must  consider  the  condition  of  his  patient  before  applying  the 
treatment,  and  modify  it  from  time  to  time  as  circumstance- 
seem  to  demand.  A  young  person  can  generally  endure  such 
restraint  as  shall  favor  consolidation,  and  some  old  people 
bear  up  remarkably  \vell  under  confining  influences  for  weeks 
together.  The  diet  should  be  nourishing  and  easily  digested  ; 
the  liowcls  need  not  be  disturbed  by  frequent  evacuations  ; 
and  an  anodyne  may  be  taken  to  allay  severe  pain. 

The  question  may  arise  among  those  who  have  few  oppor- 
tunities to  treat  fractures  of  the  cervix  femoris.  either  within 
or  without  the  capsule,  or  through  the  t rochanters.  why  an 
effort  need  be  made  to  distinguish  one  fracture  from  the  other, 
since  the  same  kind  of  treatment  is  recommended  for  all  of 
them?  Practically  it  is  not  of  vital  importance  to  discrimi- 
nate between  the  different  forms  of  lesion,  and  to  truce  the 
line  of  separation  with  the  idea  that  nothing  serviceable  can 
be  done  till  the  course  of  the  fracture  has  been  established  be- 
yond a  doubt;  yet  it  is  an  accomplishment  worth  possessing 
to  be  able  to  tell  the  patient,  that  the  case  is  one  of  intra-cap- 
sular  fracture,  and  that  such  injuries  generally  unite  with  lig- 
amentous  material,  and  that  permanent  lameness  may  be  ex- 
pected ;  or,  that  the  fracture  is  one  of  the  extra-eapsular 
variety,  and  ossitic  union  may  reasonably  be  anticipated.  In 
a  mixed  or  doubtful  case  the  best  surgeons  must  acknowledge 
the  imperfection  of  the  art  of  diagnosis  and  the  uncertainty  of 
the  result  of  the  injury,  even  when  scientifically  treated.  Im- 
paction  is  a  condition  favorable  to  bony  union  ;  and  impaction 
generally  arises  from  a  heavy  fall  on  the  trochanter,  driving 
the  cylindrical  and  perhaps  sharpened  cervix  into  the  cancel- 
lated structures  of  the  expanded  part  of  the  bone. 

It  is  to  be  borne  in  mind  that  an  intra-capsular  fracture 
generally  occurs  in  old  subjects,  from  a  trip  of  the  foot  on  the 
carpet,  or  from  some  trivial  cause,  and  commonly  not  from  a 


190  FRACTURES. 

fall  on  the  troehanter ;  that  the  shortening,  eversion,  and  other 
familiar  signs  attend  extra-capsular  fractures,  and  are 
therefore  not  differential  or  distinctive  in  character  ;  but  in  a 
simple  fracture  wholly  within  the  capsule,  the  limb  appears 
flabby,  powerless,  immovable,  and  as  if  paralyzed,  with  the 
whole  expression  altered. 

In  extra-capsular  fractures,  whether  impacted  or  not,  bony 
union  may  be  expected,  though  the  excess  of  callus  employed 
in  the  repair  of  the  injury,  is  likely  to  impede  motion,  and  to 
create  considerable  local  deformity.  In  the  event  of  shorten- 
ing after  consolidation,  the  detect  may  be  partly  remedied  by 
a  higher  heeled  shoe.  Exercise  facilitates  the  removal  of  ir- 
regular and  sharp  projections,  and  helps  to  restore  strength  to 
the  limb,  and  confidence  in  putting  it  to  use. 

When  called  to  take  charge  of  a  fractured  hip,  the  surgeon 
should  place  himself  right  with  the  patient  and  friends  by  ex- 
plaining the  nature  of  the  injury,  and  the  probabilities  of  a 
good  or  imperfect  result.  The  prognosis  should  be  carefully 
guarded,  for  old  people  frequently  die  from  the  irritation  and 
restraint  consequent  upon  fracture  of  the  femur.  Bed  sores 
upon  the  sacrum  and  sloughs  upon  the  heel  render  the  patient's 
sufferings  exceedingly  irksome.  Loops  let  down  from  the 
ceiling  where  the  patient  can  grasp  them  with  the  hands,  to 
assist  in  movements  of  the  body,  serve  an  excellent  purpose. 
Little  comforts  are  highly  appreciated,  and  if  brought  about 
by  the  surgeon's  suggestions  they  add  to  his  reputation  for  skill 
and  attention.  A  piece  of  buckskin  large  enough  to  cover 
the  excoriated  hips  of  a  bedridden  patient,  may  save  a  great 
deal  of  distress,  and  contribute  much  to  the  healing  of  irritated 
and  ulcerated  parts.  Dressed  deer-skin,  with  the  hair  left  on, 
is  often  exceedingly  agreeable.  The  soft  leather  is  much  more 
comfortable  to  the  irritated  skin  than  any  kind  of  cloth. 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 

Fractures  occurring  below  the  lesser  troehanter,  and  above 
the  condyles,  properly  belong  to  the  shaft  of  the  bone.  The 
line  of  separation  is  not  confined  to  any  particular  locality, 
but  is  found  in  the  upper,  middle,  and  lower  thirds.  The 
point  a  little  above  the  center  of  the  bone  is  more  liable  to 


OF  THE  SHAFT  OF  THE  FEMUR.  191 

yield  to  indirect  violence  than  any  other.  The  greatest  num- 
ber of  cases  coming  under  my  observation  presented  a  fracture 
a  few  inches  below  the  trochanters.  The  bone  has  generally  ;i 
little  sharper  curve  in  that  region  than  pervades  the  entire 
shaft,  which  may  be  the  reason  that  the  accident  occurs  so 
often  at  that  point.  It  has  been  a  question  whether  the  shaft 
of  the  femur  is  broken  most  frequently  by  indirect  violence, 
as  in  falls,  when  the  person  strikes  upon  the  feet,  and  has  the 
force  transmitted  upwards  to  the  thigh  bone  ;  or  by  direct 
violence,  as  a  blow,  or  the  passage  of  a  wheel  over  the  limb. 
The  prevailing  impression  among  surgical  writers  upon  the 
subject,  is  that  the  direct  application  of  force  breaks  more 
femurs  than  indirect  agencies. 

Those  who  have  had  limited  experience  in  the  management 
of  broken  femurs  are  exceedingly  prone  to  talk  of  oblique  and 
transverse  fractures  of  the  bone,  as  if  one  or  the  other  variety 
was  certain  to  take  place;  and  as  if  being  particular  in  calling 
attention  to  the  direction  of  the  line  of  separation  was  an  in- 
dication of  wisdom  concerning  the  subject.  As  has  already 
been  stated  in  another  place,  it  is  seldom  that  a  fracture  is 
wholly  oblique,  or  wholly  transverse,  but  an  irregular  and 
mixed  condition  prevails,  the  line  of  separation  being  oblique 
in  some  places  and  transverse  in  others.  The  broken  surfaces 
in  a  fractured  femur,  present  many  serrations  which  may  in- 
terlock and  prevent  overlapping,  but  the  general  course  of  the 
line  of  separation  partakes  of  a  predominant  obliquity  in  the 
majority  of  cases.  Unless  the  fracture  be  compound,  one 
fragment  being  driven  out  through  the  flesh,  the  direction  of 
the  line  of  separation  is  not  always  easy  to  determine,  for  the 
depth  of  the  soft  tissues  is  too  great  to  admit  of  such  a  dis- 
crimination. 

The  prevailing  opinion  seems  to  be  that  it  is  exceedingly 
difficult  to  treat  successfully  an  oblique  fracture  ;  the  presump- 
tion being  that  broken  surfaces  with  much  obliquity  favor 
overlapping,  and  surfaces  fractured  transversely,  if  held  in 
apposition,  will  prevent  overriding  and  the  attendant  shorten- 
ing. However,  it  will  be  found  of  .very  little  importance 
practically  whether  the  line  of  separation  be  transverse,  ob- 
lique, or  a  compound  of  the  two  directions.  If  the  limb  be 
properly  treated  there  will  be  little  or  no  shortening  ;  and  if 
managed  improperly  there  will  be  shortening,  though  the  line 


192 


FRACTURES. 


of  separation  be  transverse.  If  the  accident  occur  from 
direct  violence,  the  line  of  separation  between  the  fragments 
is  more  transverse  than  oblique;  and  if  the  fracture  arise 
from  indirect  violence  the  greater  will  be  the  obliquity. 


FRACTURES  OF  THE  UPPER  THIRD  OF  THE 
SHAFT,  BELOW  THE  TROCHANTKKS. 

Quite  a  common  place  for  fracture  of  the  femur  to  occur  is 
at  a  point  a  few  inches  below  the  trochanter  minor.  It  is  a 
place  where  the  muscular  forces  greatly  influence  the  relative 
positions  of  the  fragments,  and  oppose  in  some  degree  the  in- 
fluence of  the  dressings.  There  is  always  con>iderable  dis- 
placement whether  the  fracture  be  oblique  or  transverse.  The 
>wer  fragment  is  drawn  upwards,  backwards,  and  a  little  in- 
wards, and  the  upper  fragment  is  drawn  forwards,  and  a  little 
outwards,  causing  an  overlapping  of  two  or  three  inches,  with 
the  position  of  the  fragments  as  represented  in  the  accompany- 
ing diagram.  The  lower  fragment  sometimes  acts  upon  the 

FKI.  74. 


I-'nirtui-"  through  the  upper  third  of  the  shaft  of  UK-  t'cmur,  slum- ing  th.*  tendency 

of  th<'  fnijTiiH-nrs  10  overlap. 

upper,  making  it  project  forwards  and  outward-,  contributing 
to  produce  angular  distortion.  Sir  Astley  Cooper  and  his  fol- 
lowers have  attributed  this  position  of  the  upper  fragment 
solely  to  the  action  of  the  psoas  and  iliacus  muscles.  •'  And,'' 
says  Mr.  Cooper,  "to  prevent  this  horrid  distortion  two  cir- 
cumstances ought  strictly  to  be  observed;  the  one  is,  to  ele- 
vate the  knee  very  much  over  the  double  inclined  plane  ;  and 
the  other,  to  place  the  patient  in  a  sitting  position,  supporting 
him  by  pillows  during  the  process  of  union."  The  distortion, 
however,  is  in  some  measure  due  to  the  forces  acting  on  the 
lower  fragment,  and  to  a  certain  degree  upon  the  forces  which 
produced  the  injury.  The  psoas,  iliacus,  and  pectineus  mus- 


OF  THE  FEMUR.  193 

cles  tend  to  elevate  the  lower  end  of  the  upper  fragment,  but 
not  to  the  extent  claimed  by  Mr.  Cooper. 

Muscular  action  being  deprived  of  its  normal  influence  upon 
the  bone  in  consequence  of  the  fracture,  exerts  forces  upon 
the  fragments  of  a  rotatory  character,  so  that  the  periphery 
of  one  piece  does  not  correspond  to  that  of  the  other  piece. 
It  is  difficult  to  discover  this  defect,  and  to  remedy  it,  although 
the  limb  will  not  be  restored  perfectly  to  usefulness  if  such  a 
defect  exist. 

The  symptoms  of  fracture  of  the  shaft  of  the  femur  below 
the  trochanters  are  similar  to  those  met  in  other  fractures  of 
the  long  bones.  Pain,  swelling,  and  deformity  are  prominent 
characteristics  ;  inability  to  move  the  limb  or  to  bear  weight 
upon  it,  is  a  necessary  condition  ;  great  mobility  at  the  seat  of 
injury  may  be  expected,  as  well  as  crepitus  when  the  broken 
surfaces  are  made  to  confront  one  another.  The  shortening- 
is  marked,  amounting  in  some  instances  to  several  inches. 
Lmpaction  is  very  rare,  therefore  the  shortening  is  due  to  over- 
lapping and  angular  deformity  Eversion  of  the  foot  is  gen- 
erally observahle,  as  if  the  limb  naturally  inclined  to  roll  out- 
ward, tailing  powerless  and  subject  alone  to  gravity.  In  rare 
instances  the  lower  fragment  is  found  in  front  of  the  upper,  a 
position  into  which  it  may  have  been  forced  by  the  power 
which  produced  the  fracture.  And  when  the  upper  fragment 
is  thus  behind  the  other,  the  psoas  and  iliacus  do  not  tilt  the 
lower  end  of  the  upper  fragment  forward,  making  a  marked 
prominence  on  the  anterior  aspect  of  the  thigh,  except  in  cases 
where  the  breaking  force  threw  the  fragments  into  that  posi- 
tion. In  such  instances  there  is  no  force  in  the  muscles  com- 
petent to  radically  alter  the  position  of  the  fragments  or  to 
change  their  relative  positions. 

TREATMENT. — There  are  two  distinct  attitudes  in  which  the 
leg  may  be  placed  in  the  management  of  fractures  below  the 
trochanters:  one  is  the  straight  position  of  the  limb,  and  was 
always  employed,  so  far  as  is  known,  until  Percival  Pott,  a 
little  more  than  a  century  ago,  came  out  with  his  "  physio- 
logical "  notions  in  regard  to  the  position  the  limb  should  be 
made  to  assume  during  the  treatment  of  fractures  of  the 
thigh.  Mr.  Pott  claimed  that  the  muscles  caused  displacement 
of  the  fragments  while  in  a  state  of  tension,  and  therefore  sug- 
13 


194  FRACTUKES. 

gested  that  their  contractile  forces  could  be  neutralized  by 
posture  alone  ;  and  he  proposed  to  flex  all  the  parts  involved  in 
a  fracture  in  order  to  secure  apposition  of  fragments  without 
the  employment  of  force.  For  instance,  if  he  wished  to  treat 
a  patient  with  a  fractured  femur,  he  flexed  the  leg  upon  the 
thigh,  and  the  thigh  upon  the  abdomen,  and  kept  the  limb  in 
that  position  for  several  weeks,  using  no  splints,  junks,  or 
other  mechanical  contrivances  to  keep  the  fragments  at  rest, 
and  to  perform  extension.  This  bold  and  seemingly  rational 
plan  created  a  revolution  in  the  ideas  of  English  surgeons; 
and  among  its  able  supporters  was  Sir  Astley  Cooper,  who 
added  mechanics  to  physiology.  He  placed  the  flexed  limb 
upon  a  double  inclined  plane,  by  which  the  muscles  were  re- 
laxed, the  weight  of  the  leg  on  an  inclined  plane  estab- 
lished extension,  and  the  weight  of  the  body  and  the  upper 
part  of  the  thigh,  produced  counter-extension.  The  elevation 
of  the  lower  part  of  the  thigh  made  the  lower  fragment  cor- 
respond to  the  pitch  the  upper  fragment  generally  assumed. 
Mr.  Amesbury,  a  little  later,  modified  the  simple  double  in- 
clined plane  of  Cooper,  by  adding  to  it  means  for  producing 
active  extension  and  counter-extension.  American  surgeons 
have  improved  upon  the  splint  of  Amesbury,  though  all  in- 
volve the  physiological  principle  adopted  by  Pott,  and  the 
additional  mechanical  principle  of  Cooper.  At  length  a  reac- 
tion took  place  in  the  minds  of  European  and  American  sur- 
geons ;  and  though  the  straight  and  the  flexed  plans  of  treat- 
ing fractures  of  the  thigh  are  both  in  reputable  use,  the  method 
of  treatment  with  the  long  straight  splint  is  followed  in  nearly 
all  the  hospitals  at  home  and  abroad.  In  the  rural  districts 
of  this  country  the  double  inclined  plane  apparatus  is  in  com- 
mon use.  Whether  the  Pott  and  Cooper  plans  have  certain 
captivating  ideas  in  connection  with  them  that  readily  per- 
suade the  country  practitioner ;  or  the  "  sets  "  of  fracture 
splints  and  appliances,  all  of  which  embrace  a  double  inclined 
plane  apparatus,  with  attractive  illustrations  to  show  the  prac- 
tical workings  of  the  splints,  now  hawked  about  from  town  to 
town,  contribute  to  the  belief  that  all  eminent  surgeons  em- 
ploy such  in  their  practice,  are  subjects  of  interesting  inquiry. 
That  truly  great  and  illustrious  surgeon,  the  late  Dr.  Valentine 
Mott,  never  "  reacted,"  or  went  back  to  the  straight  attitude 
for  a  fractured  thigh.  He  once  said  to  his  class,  in  my  hear- 


OF  THE  FEMUR. 


195 


ing1,  that  if  he  should  ever  be  so  unfortunate  as  to  sustain   a 

O  " 

fracture  of  the   femur,  he  should  insist  on  having  it  treated 
upon  the  double  inclined  plane. 

The  straight  splint  is  a  piece  of  board  nearly  an  inch  thick, 
and  about  four  inches  Avide,  pierced  with  two  holes  at  its 
upper  end,  and  notched  two  or  three  times  at  its  louver 
end,  and  long  enough  to  reach  from  the  borders  of  tlie 
axilla  to  four  inches  below  the  foot.  The  splint  should  be 
well  padded  its  whole  length  ;  and  the  pad  should  be  pierced 

FIG.  75. 


The  "  straight  splint"  applied.    The  cushion  to  be  used  between  the  splint  and  the 
patient's  limb,  is  represented  by  the  upper  object  of  the  wood-cut. 

with  holes  corresponding  to  those  in  the  splint,  so  that  the 
ends  of  the  perineal  bands  may  slip  through  them  easily,  and 
be  loosened  or  tightened  as  occasion  may  require.  The  peri- 
neal band  may  be  a  silk  pocket  handkerchief,  a  wide  strip  of 
buckskin,  or  any  belt  of  strong  and  unirritating  material.  It 
is  to  be  long  enough  to  reacn  through  the  perineum  between 
the  genitals  and  the  thigh,  one  end  extending  in  front,  along 
the  groin,  and  the  other  behind  the  buttock,  to  the  holes  in 
the  splint  through  which  the  tAvo  ends  pass,  to  be  tied  in  a 
bow-knot.  In  applying  the  apparatus,  the  surgeon,  after  ad- 
justing the  fracture,  takes  the  perineal  band  and  applies  it  to 
the  patient's  perineum,  bringing  up  one  end  in  front  of,  and 
the  other  behind  this  part  of  the  body.  He  then  lays  the 
splint  along  the  outer  side  of  the  affected  limb,  against  a  long 
cushion  to  protect  tender  parts,  and  proceeds  to  fasten  the 
foot  to  the  notches  in  the  lower  end  of  the  appliance.  Before 
doing  this,  it  is  a  good  plan  to  bandage  the  foot  and  ankle 


196  FRACTURES. 

with  a  flannel  roller  in  the  ordinary  way,  to  protect  them  from 
the  pressure  of  the  splint,  and  to  prevent  them  from  swelling  ; 
or,  instead  of  this,  the  foot  may  be  enveloped  in  a  layer  of 
cotton-wool.  The  surgeon  should  then  take  a  muslin  roller, 
and  make  a  few  turns  round  the  foot  and  ankle  in  the  form 
of  a  figure-of-8,  so  as  to  obtain  a  tirm  hold;  after  which  he 
should  carry  the  bandage  in  a  regular  way  round  the  ankle 
and  through  the  notches  in  the  lower  end  of  the  splint,  so  as 
to  fasten  it  securely  to  the  foot.  He  should  then  get  an  assist- 
ant to  make  extension  from  the  foot  while  he  draws  the  peri- 
neal  band  tight,  and  ties  it  in  a  bow  on  the  outer  side  of  the 
splint.  In  order  to  keep  the  apparatus  in  position  it  is  some- 
times necessary  to  apply  a  bandage  over  both  the  leg  and 
splint  from  the  foot  upwards  as  far  as  the  thigh,  and  also  to 
put  a  few  turns  of  a  broad  roller  round  the  patient's  chest. 
The  thigh  on  each  side  of  the  seat  of  fracture  may  have  a 
piece  of  splint  material  or  pasteboard  bound  to  it  with  tapes 
to  make  the  broken  parts  feel  more  secure.  This  dressing,  if 
well  applied,  and  no  serious  complaints  are  made,  may  stay  on 
for  weeks,  even  till  bony  union  has  taken  place.  If  at  any 
time  after  its  application,  the  dressing  produce  general  uneasi- 
ness, it  may  be  removed,,  and  the  fault,  should  any  be  found, 
corrected.  The  patient  gets  up  with  more  general  stiffness  of 
the  joints  after  this  straight  dressing  has  been  employed,  than 
after  a  double  inclined  plane  splint  has  been  used. 

The  straight  splint  is  irksome  at  first,  owing  in  part  to  the 
great  restraint  imposed  upon  so  considerable  a  portion  of  the. 
body.  However,  in  a  few  days  the  patient  gets  over  the  feel- 
ing of  being  rigidly  confined,  and  passes  the  remainder  of  tin- 
time  without  much  complaint. 

A  great  deal  may  be.  done  toward  keeping  the  fragments 
in  apposition,  by  simply  attending  to  the  position  of  the  limb, 
without  the  application  of  any  splint.  If  the  patient  has  a 
good  degree  of  self  control,  he  may  be  laid  on  his  back,  and 
the  limb  can  be  kept  straight  by  the  use  of  several  sand  bags 
placed  along  the  leg  from  the  hip  to  the  foot. 

Extension  may  conveniently  be  made  by  fastening  the  ends 
of  long  pieces  of  adhesive  plaster  to  the  sides  of  the  leg,  with 
the  ends  extending  below  the  sole  of  the  foot;  the  pieces 
should  reach  nearly  to  the  knee,  and  over  these  other  strips 
should  be  applied  in  a  circular  manner  till  the  leg  is  enveloped 


OF   THE  FEMUR.  197 

as  if  in  a  bandage.  The  circular  strips  prevent  any  slipping 
or  yielding  when  power  is  applied,  and  distribute  the  pressure 
falling  upon  the  circumference  of  the  limb.  A  short  block  of 

FIG.  76. 


Strips  of  adhesive  plaster  applied  to  the  leg  longitudinally,  and  held  from  slipping  by  the 
circular  wrapping  of  other  pieces  of  the  same  material. 

wood  a  little  longer  than  the  width  of  the  ankle  may  be  placed 
in  the  loop  after  the  long  loose  ends  are  tied  together,  to  pre- 
vent the  downward  strain  from  compressing  the  tissues  on  the 
sides  of  the  joint.  Around  this  block  and  the  loop  a  cord 
may  be  fastened,  which  then  extends  over  the  foot  of  the  bed, 
and  sustains  a  weight.  The  extension  thus  produced  need 
not  be  so  great  as  to  distress  the  patient.  Moderate  but  con- 
stant traction  upon  the  limb  is  all  that  may  be  desired. 

After  the  foot  and  leg  have  been  arranged  with  the  extend- 
ing apparatus,  the  thigh  demands  separate  attention.  The 
fragments  should  be  adjusted  while  assistants  are  producing 
temporary  extension  and  counter-extension  with  their  hands  ; 
and  then  four  or  five  common  wooden  splints  a  foot  long,  and 
two  inches  "wide,  made  of  lath  or  thin  boards,  and  evenly 
wrapped  with  cloth,  are  to  be  placed  at  a  little  distance  from 
one  another,  parallel  with  the  course  of  the  femur,  and  reach- 
ing above  and  below  the  line  of  fracture  ;  Avhere  they  are  to 
be  firmly  bound  with  tapes.  Over  all  of  these  a  roller  or  many 
tailed  bandage  is  to  be  snugly  applied.  This  part  of  the 
dressing  prevents  mobility  between  the  fragments,  and  con- 
tributes to  the  comfort  of  the  patient.  The  limb  may  be  made 
still  more  comfortable  by  placing  a  sand  bag  under  the  knee 
to  flex  it  a  little.  Extension  may  be  made  by  fastening  the 

»/  «'  O 

limb  to  the  foot  of  the  bed  by  means  of  a  cord  reaching  from 
the  loop  of  adhesive  strips  to  the  lower  bed  rail,  and  then 
raising  the  foot  of  the  bed  upon  a  couple  of  bricks  to  give  the 
patient's  body  an  inclination  toward  the  head  of  the  bed. 
This  is  the  easiest  and  most  natural  method  of  securing  ex- 


198  FRACTURES. 

tension  and  counter- extension  without  complicated  apparatus. 
Any  desired  amount  of  extending  and  counter-extending 
power  can  be  secured  by  this  arrangement.  If  the  foot  of  the 

Fig.  77. 


The  splints  upon  the  thigh  prevent  motion  between  the  fragments  of  the  femur ;  the  adhesive 

strips  upon  the  leg  and  ankle  make  a  comfortable  fastening  to  the  limb  :  the  ffistening 

is  secured  to  the  bed  rail ;  and  the  foot  of  the  bed  is  raised  on  blocks  or  bricks  to 

incline  the  patient's  body  in  the  opposite  direction. 

bed  or  lounge  be;  raised  high,  enough  to  have  the  patient's 
body  incline  effectively  in  the  opposite  direction  or  toward  the 
head  of  the  bed,  great  extending  force  may  be  brought  to 
bear  upon  the  limb.  I  have  such  confidence  in  this  manner 
of  treating  -a  fractured  thigh  that  I  feel  like  urging  its  use 
upon  my  professional  brethren.  Very  few  perfect  results  can 
be  secured  by  the  use  of  the  long  straight  splint;  and  the 
double  inclined  plane  apparatus  which  goes  with  almost  every 
"  set"  of  splints  or  fracture  appliances,  does  not  give  general 
satisfaction. 

About  one-third  of  all  cases  of  fracture  of  the  shaft  of  the 
femur,  as  ordinarily  treated  by  physicians  and  surgeons  of 
every  grade  of  skill  turn  out  favorably,  or  without  perceptible 
or  appreciable  deformity;  another  third  of  all  cases  treated 
exhibit  so  little  shortening  or  other  defects  that  in  the  course 
of  time  they  fail  to  attract  personal  or  professional  attention; 
the  remaining  third  are  so  seriously  defective,  either  from 
shortening  or  other  deformities,  that  the  patient  is  temporarily 
or  permanently  compelled  to  walk  lame,  or  forever  made  a 
cripple. 

The  defect  is  generally  shortening  which  comes  From  over- 
lapping of  the  fragments;  and,  in  addition,  there  may  be  an- 
gular deformity,  as  seen  in  the  following  diagram.  The 
shortening  in  the  cases  attracting  attention,  which  constitutes 


OF  THE  FEMUR. 


199 


about  one-third  of  all  fractures  of  tlie  shaft  of  the  femur, 
amounts  to  three  quarters  of  an  inch.  No  shortening  which 
is  less  than  half  an  inch  attracts  atten- 
tion or  proves  a  serious  source  of  com- 
plaint ;  but  in  rare  instances  the  over- 
lapping readies  several  inches. 

In  several  mal-practice  suits  in  which 
I  have  been  called  to  give  testimony  as 
an  expert,  I  have  found  the  shortening 
to  be  from  one  to  three  inches.  In  ad- 
dition to  the  shortening  there  has  gen- 
erally been  angular  deformity,  and  ex- 
cess of  callus  which  seriously  interfered 
with  the  functions  of  the  limb.  In  some 
of  these  malpractice  cases  the  fault 
seemed  to  result  from  surgical  incompe- 
tency.;  and  in  others  the  defect  may 
have  arisen  from  untoward  circumstan- 
ces beyond  the  control  of  the  profes- 
sional attendant. 


Union  of  the  fragments  with 
shortening,  and  angular  de- 
formity. 


FIG.  79. 


Extension  by  means  of  a  weight  and  pulley;  counter-extension  is  produced  by  a  perinea  1 
band  which  may  be  fastened  to  the  head  of  the  bed. 


WEIGHT  AND  PULLEY  FOR  MAKING  EXTENSION. — Another 
method  of  applying  extension  in  the  treatment  of  a  broken 
femur,  consists  in  employing  weight  to  a  cord  which  reaches 
from  the  loop  of  adhesive  strips  over  the  foot  rail  of  the  bed. 
The  fastening  to  the  limb  may  bt>  made  with  a  piece  of  belt 


200 


FRACTURES. 


leather  secured  to  the  thigh  above  the  knee  with  lacings. 
This  leather  band  may  have  loops  fastened  to  each  side  of  it5 
from  which  cords  extend  over  the  foot  of  the  bed  for  the  pur- 
pose of  sustaining  weight.  It  is  well  to  have  the  knee  gently 
flexed  by  means  of  a  sand  bag  or  cushion  placed  under  the 
joint.  Instead  of  producing  counter- extension  with  a  peri- 
neal  belt,  the  foot  of  the  bed  may  be  raised  on  blocks,  to  give 
the  patient's  body  an  inclination  in  the  direction  of  the  head 
of  the  bed.  This  dressing  is  not  complete  without  straight 
splints  are  bound  to  the  thigh  ;  and  sand  bags  used  to  obviate 
rotation. 

Mr.  Burge,  of  New  York,  has  invented  an  apparatus  for 
treating  fracture  of  the  femur,  which  is  represented  by  the 
accompanying  diagram.  The  machine  has  been  successfully 
employed  in  some  of  the  New  York  hospitals.  It  holds  the 

FIG.  80. 


Barge's  fracture  apparatus  applied. 

limb  in  the  straight  attitude,  but  allows  the  patient  to  take  the 
sitting  posture;  and  provides  for  the  escape  of  alvine  evacua- 
tions without  disturbing  the  fragments  of  bone.  Various  in- 
tricate contrivances  have  been  devised  to  treat  fractures  of  the 
femur,  but  it  is  questionable  whether  they  are  superior  to  the 
more  simple  plans  already  described.  The  most  of  them  are 
too  costly  for  the  ordinary  practitioner  who  might  not  have 
an  opportunity  once  in  ten  years  to  put  one  of  them  in  prac- 
tice. To  study  the  different  parts  entering  into  the  Burge 
apparatus,  for  instance,  would  require  more  time  than  to  dress 
a  limb  with  more  simple  means.  To  a  practitioner  inexpe- 
rienced in  the  different  machines  invented  to  treat  fractu !•<•.-• 


OF  THE  FEMUR. 


201 


FIG.  81. 


-of  the  thigh,  the  diagrams  representing  such  apparatus  in 
works  on  surgery,  oft'er  more  confusion  than  illustration.  Tho 
fracture  beds  of  Jenks,  Daniels,  IJurge.  and  others,  cost  from 
fifty  to  a  hundred  dollars,  therefore  the  surgeon  of  limited 
pecuniary  means  could  ill  afford  to  possess  one  or  more  of 
them. 

A  fractured  femur  needs  to  be  treated  with  retentive  means 
for  a  period  of  six  or  eight  weeks  in  the  young  and  vigorous, 
and  for  ten  or  twelve  weeks  in  patients  advanced  in  years. 
A  limb  may  appear  firm,  as  if  consolidation  had  taken  place 
at  the  end  of  five  weeks,  yet  it  is  not  safe  to  lay  aside  the 
dressings  and  trust  the  patient  on  crutches  lest  shortening 
occur.  As  has  been  remarked  in  another  place,  the 
uniting  material  continues  soft  and  yielding  for  many  weeks 
after  osseous  consolidation  between  the  fragments;  seems  to 
have  been  effected.  Many  a  surgeon  of  large 
experience  in  treating  fractures  has  dis- 
charged his  patient  with  one  leg  as  long  as 
the  other,  and  has  been  astonished  some 
weeks  after  to  find  that  shortening  had  taken 
place.  It  may  be  remarked  in  this  connec- 
tion, that  there  is  no  way  to  determine  when 
the  fragments  are  so  far  consolidated  that 
shortening  will  not  take  place.  Experience 
shows  that  the  uniting  medium  generally  be- 
comes unyielding  at  the  expiration  of  ten  or 
twelve  weeks  after  the  reception  of  the  frac- 
ture. In  young  patients  seven  or  eight  weeks 
may  be  long  enough  to  continue  the  retentive 
dressing.  I  have  never  had  occasion  to  cen- 
sure myself  for  keeping  a  fractured  thigh  in 
its  dressing  too  long;  but  several  times  I 
have  regretted  having  laid  the  apparatus 
aside  too  soon. 

After  the  fracture  has  heconie  consolidated 
there  remains  at  the  seat  of  injury  an  enlarge- 
ment  which  may  annoy  a  nervous  patient- 

rm          i  i  .n        /?  .1 

TlllS  hypertrophy  CO1TIOS  mostly  from  tllC   6X- 

„  .  .     ,  ,  -,     .          , 

cess  ot  reparative  material  employed  in  the 
At  first  the  lack  of  perfect  apposition  of  the 


permanent  enlarge- 
mental  line  of  unfon 
:mrl  slight  singular 

deformity. 
healing  process. 


fragments  may  present  some  sharp  and  jagged    edges,  which 


202  FRACTURES. 

will  irritate  the  soft  tissues,  and  paralyze  the  muscles  to  some 
extent,  but  in  time  the  rough  points  will  be  removed  by  ab- 
sorption, and  the  enlargement  will  be  forgotten. 

A  moderate  degree  of  angular  deformity  will  not  prove  a 
serious  impediment  to  locomotion,  therefore  it  should  not  be 
meddled  with  in  old  cases.  Unless  the  defect  be  very  great, 
any  attempt  to  break  the  femur  over  again  is  not  justifiable. 
In  extreme  angular  deformities  an  awl  or  drill  may  be  used  to 
perforate  the  bone  at  the  point  of  union,  until  there  is  so  little 
osseous  material  left  that  it  can,  with  proper  apparatus,  be 
pressed  into  line,  or  re-broken,  when  the  limb  can  be  treated 
in  the  straight  attitude  until  the  fragments  re-unite.  It  may 
be  incidentally  remarked,  that  the  lameness  dependent  upon 
shortening,  generally  diminishes.  The  twisting  of  the  pelvis 
and  the  vertebral  column  tend  to  conceal  the  defect.  A 
higher  heeled  shoe  worn  on  the  lame  side  will  improve  the 
gait. 

FRACTURES  OF  THE  MIDDLE  THIRD  OF  THE 

FEMUR. 

The  middle  of  the  shaft  of  the  femur  is  broken  about  as 
frequently  as  those  parts  of  the  bone  near  the  extremities ; 
and  when  a  fracture  exists  near  the  centre  of  the  bone,  the 
manner  of  treatment  does  not  differ  essentially  from  that  de- 
manded at  points  some  distance  from  the  middle  line.  The 
same  forces  which  break  the  femur  at  points  higher  or  lower 
in  the  bone,  may  produce  a  fracture  of  the  middle  third  ;  and 
the  signs  of  the  injury  could  not  be  substantially  different 
from  those  in  fractures  through  other  parts  of  the  bone. 
There  would  be  inability  to  move  the  limb,  e version  of  the 
foot,  shortening,  angular  deformity,  and  crepitus  when  the 
broken  ends  of  the  fragments  were  brought  in  contact.  The 
mobility  at  the  seat  of  the  injury  would  be  so  marked  that 
even  the  unprofessional  observer  could  not  fail  to  recognize 
the  nature  of  the  lesion.  The  line  of  separation  between  the 
fragments  may  be  oblique,  transverse,  or  intermediate  between 
those  directions,  partaking  in  part  of  each.  There  is  the  same 
tendency  for  the  fragments  to  overlap,  producing  shortening, 
as  after  fractures  higher  up  or  lower  down  the  shaft  of  the 
femur.  The  same  dressing  will  be  required  as  for  a  fracture 


Or  THE  FEMUR.  203 

just  below  the  lesser  trochanter ;  there  will  be  the  same 
danger  of  defects  and  deformities  as  in  fractures  at  other 
points  in  the  bone  ;  and  it  will  require  about  the  same  length 
of  time  for  the  reparative  forces  to  effect  consolidation  of  the 
fragments.  "  These  fractures,"  says  Malgaigne,  "  when  sim- 
ple and  without  displacement,  unite  in  forty  or  fifty  days; 
sometimes  they  require  two  or  three  months,  when  the 
fragments  overlap  one  another,  being  in  contact  only  by  their 
lateral  surfaces.  When  the  two  ends  can  not  be  made  to 
oppose  one  another,  so  as  themselves  to  counteract  the  mus- 
cular contractions,  it  is  impossible  to  preserve  the  normal 
length  of  the  limb,  whatever  be  the  apparatus  or  method  em- 
ployed. There  has  been  too  much  discrepancy  of  opinion 
among  surgeons  in  regard  to  this.  Hippocrates  gives  the  idea 
that  the  shortening  can  always  be  obviated ;  Celsus  goes  to 
the  opposite  extreme,  declaring  that  a  thigh  once  broken  must 
ever  remain  shorter  than  its  fellow.  At  a  period  by  no  means 
remote  from  our  own,  Desault  claimed  to  cure  all  fractures 
without  shortening,  and  his  journal  contains  several  such 
cases.  In  imitation  of  him  many  surgeons  have  varied,  cor- 
rected, and  improved  apparatus  for  permanent  extension,  and 
have  announced  as  complete  successes  from  them.  I  must, 
however,  state  positively  that  I  have  never  obtained  anything 
of  the  kind,  either  with  contrivances  of  my  own,  or  with 
those  of  others,  or  even  when  I  have  invited  the  inventors  of 
such  apparatus  to  apply  them  in  my  wards.  I  have  more  than 
once  examined  persons  said  to  be  cured  without  any  shorten- 
ing, but  always  discovered  such  shortening  by  actual  measure^ 
ment.  Some  have  deceived  themselves  in  regard  to  the  merits 
of  their  treatment;  they  have  happened  to  meet  with  fractures 
in  which  there  could  be  no  overlapping  on  account  of  an  in- 
terlocking of  the  serrations,  and  imagined  they  had  corrected 
a  shortening  which  never  existed.  Ju  short,  when  the  frag- 
ments remain  in  contact,  or  when  we  can  replace  them  and 
keep  them  so  by  means  of  their  serrations,  it  is  easy  to  cure  a 
fracture  of  the  femur  without  shortening  ;  in  the  absence  of 
these  two  conditions  the  thing  is  simply  impossible. 

"  Several  distinguished  surgeons  of  the  present  day,  recogniz- 
ing this  impossibility,  have  abandoned  the  idea  of  permanent 
extension.  They  allege  moreover  that  an  overlapping  of  even 
as  much  as  an  inch  is  of  slight  consequence,  and  involves  no 


204  FRACTURES. 

limping.  I  can  not  entertain  this  view.  I  have  seen  persona 
walk  very  well  with  one-third  of  an  inch  shortening,  but  with 
more  than  this  they  either  limp,  or  must  wear  a  thick  soled 
shoe;  or  possibly  their  halt  is  masked  by  a  lateral  inclination 
of  the  spine.  Hence  we  see  how  grave  a  fracture,  with  over- 
lapping, must  always  be,  and  what  caution  we  should  observe 
in  giving  a  prognosis." 

Although  the  upper  fragment  rides  usually  upon  the  lower, 
and  the  tension  of  the  muscles  seems  to  favor  the  flexed  or 
"  physiological  position"  recommended  by  Pott,  Cooper,  and 
others,  many  of  the  most  experienced  surgeons  of  the  present 
day,  both  in  Europe  and  America,  employ  the  long  straight 
splint,  instead  of  the  double  inclined  plane,  to  treat  fractures 
near  the  middle  of  the  thigh.  To  the  latter  plan,  Desault 
makes  the  following  objections:  "the  difficulty  of  making- 
extension  and  counter-extension  while  the  limb  is  in  a  state 
of  flexion — the  impossibility  of  comparing,  with  precision,  the 
injured  thigh  with  that  of  the  sound  side,  in  order  to  judge 
of  the  regularity  of  the  conformation — the  uneasiness  which 
this  position  continued  for  a  long  time  occasions,  although  at 
first  it  may  appear  natural — the  inconvenience  and  painful 
pressure  of  a  part  of  the  trunk  upon  the  great  trochanter  of 
the  injured  side — the  derangement  to  which  the  limb  is  ex- 
posed when  the  patient  goes  to  stool — the  difficulty  of  fixing 
the  limb  sufficiently  to  prevent  movements  of  the  femur — the 
evident  impossibility  of  this  method  when  the  two  thighs  are 
fractured — lastly,  experience  so  little  favorable  in  France  to 
this  position."  Such  were  the  motives,  says  L<msdale,  which 
determined  Desault  to  have  recourse  to  it  no  more,  after  hav- 
ing tried  it  on  two  patients,  one  of  whom  had  a  considerable 
shortening,  in  spite  of  the  most  scrupulous  attention. 

The  objections  to  a  flexed  condition  of  the  limb  over  a 
double  inclined  plane,  as  offered  by  Desault,  are  unworthy  so 
eminent  a  surgeon.  The  experiment  upon  only  t^o  patients 
was  too  limited  for  a  weighty  argument ;  and  then  to  say  that 
experience  was  against  the  position,  shows  that  prejudice  ex- 
ercised an  undue  influence  over  his  mind.  It  is  unfortunate 
that  no  tables  are  drawn  up  to  show  under  which  plan  of 
treatment  the  least  amount  of  shortening  occurs. 

I  have  had  the  best  success  with  cases  managed  .with  a  sand 
hair  under  the  partially  flexed  knee,  and  extension  applied 


OF  THE  FEMUR.  205 

from  the  leg  by  means  of  adhesive  strips,  the  counter  extend- 
ing force  being  derived  from  the  descent  produced  by  elevating 
the  foot  of  the  bed.  A  firm  mattress  is  quite  essential  to  the 
carrying  out  of  several  points  in  the  treatment.  In  a  soft 
leather  bed  it  is  quite  impossible  to  bolster  up  the  leg  to  obvi- 
ate eversion,  and  to  determine  how  the  dressing  is  accomplish- 
ing its  various  objects.  On  a  mattress  every  indication  <-an 
be  fulfilled,  and  every  defect  watched  and  guarded  against. 
I  believe  in  securing  every  advantage  that  can  be  derived 
from  position.  Kven  while  using  the  long  straight  splint,  the 
limb  may  be  made  fast  to  the  foot  of  the  bed,  and  the  body 
given  an  inclination  toward  the  head  of  the  bed  by  elevating 
the  lower  parts  as  already  indicated.  However,  there  is  no 
ue'cessity  for  complicating  the  means  if  the  straight  splint  ac- 
complishes all  that  may  be  desired.  Experience  teaches  that 
very  lew  cases  of  fracture  of  the  shaft  of  the  femur  ean  be 
trusted  without  some  kind  of  extending  and  counter-extend- 
ing forces  being  employed  clear  through  the  course  of  treat- 
ment. 

The  double  inclined  plane  fracture  appliance  of  Amesbury, 
and  kindred  contrivances,  may  possess  principles  which,  if 
earried  into  execution  by  surgeons  possessing  mechanical 
skill,  might  secure  the  happiest  recoveries  ;  but  the  complica- 
tions of  the  machines  often  confuse  the  professional  attendant, 
and  lead  him  to  trust  more  to  the  apparatus  than  he  would  to 
a  contrivance  easier  to  be  understood.  I  recently  saw  a 
patient  under  treatment  for  fracture  near  the  middle  of  the 
femur;  and  the  double  inclined  plane  splint  of  artistic  con- 
struction was  performing  its  part  so  badly  that  I  asked  the 
doctor  what  he  designed  to  accomplish  with  the  appliance? 
He  appeared  unable  to  explain  what  the  machine  ought  to 
perform,  yet  expressed  confidence  in  the  powers  of  the  appa- 
ratus to  avert  deformity  in  the  limb.  If  he  had  understood 
what  the  broken  femur  needed,  he  could  have  used  almost 
any  method  to  accomplish  the  object ;  but  having  no  rational 
theory  in  regard  to  the  wants  of  the  case,  he  trusted  blindly 
to  the  virtues  of  the  appliance.  The  thigh-piece  of  the  splint 
was  so  short  that  the  body  of  the  patient,  bolstered  up  with  pil- 
lows and  other  material,  slid  down  against  the  apparatus,  pro- 
ducing an  angle  and  overlapping  at  the  line  of  fracture,  which 
would  not  have  occurred  if  the  limb  had  laid  straight  on  a  mat- 


206  FRACTUKES. 

tress,  no  dressing  being  employed.  The  splint  was  so  defec- 
tive, or  was  so  faultily  applied,  that  the  case  was  damaged  by 
the  treatment.  In  a  soft  bed,  with  the  narrow  double  inclined 
plane  splint  toppling  about,  and  the  body  pressing  down 
against  the  fracture,  there  is  little  hope  of  a  reputable  cure. 
The  double  inclined  plane  under  such  circumstances  ig  infin- 
itely inferior  to  the  long  straight  splint  of  Desault.  With  the 
"  physiological  method  "  so  imperfectly  or  wretchedly  put  into 
practice,  it  is  no  wonder  a  reaction  in  favor  of  the  old-fashioned 
straight  dressing  took  place. 

American  surgeons  have  displayed  much  ingenuity  in  con- 
structing apparatus  for  treating  fractures  of  the  leg.  Not  less 
than  half  a  dozen  have  gotten  their  names  associated  with 
splints.  Dr.  Wm.  Gibson  introduced  an  apparatus  with  a 
couple  of  long  splints  reaching  from  the  axilla  down  on  each 
side  of  the  trunk  and  legs  to  a  foot-piece,  to  which  the  feet 
of  the  patient  were  secured.  This  kept  both  legs  parallel  and 
the  body  straight  with  them ;  and  prevented  lateral  twisting 
and  swaying,  and  served  as  a  kind  of  litter  to  raise  the  patient 
for  defecation.  The  foot-piece  could  be  moved  up  and  down 
on  the  straight  pieces,  and  held  at  any  desired  place  by  means 
of  holes  and  pegs.  The  upper  crutch -headed  extremities 
rested  in  the  axillae,  and  the  movements  of  the  foot-board 
downwards  secured  the  necessary  traction.  Dr.  Joseph  Ilarts- 
horne  used  a  similar  apparatus,  though  only  one  splint  reached 
the  arm-pit,  the  other  being  placed  on  the  inside  of  the  broken 
leg,  reaching  to  the  perineum,  with  a  crutch-like  head  to  pre- 
vent excoriation.  The  foot-piece  was  moved  by  means  of  a 
wooden  screw  passing  through  a  cross-piece.  None  of  these 
more  or  less  ingenious  contrivances  are  so  simple  and  effective 
as  the  adhesive  plaster  extending  apparatus,  with  elevation  of 
the  foot  of  the  bed  for  counter-extension.  Besides,  this 
method  leaves  the  thigh  free  to  be  dressed  with  common  re- 
tentive means. 

In  fractures  somewhere  near  the  middle  of  the  thigh,  the 
immovable  or  starch  dressing  may  be  applied  about  the  eighth 
day,  and  then  the  foot  can  be  released  from  powerful  traction. 
A  compound  injury  is  to  be  treated  like  a  simple  fracture, ex- 
cept the  puncture  in  the  flesh  is  to  be  left  open  to  facilitate 
discharges. 


OF  THE  FEMUR. 


207 


False-joint  is  an  unfortunate  termination,  which  may  happen 
in  any  case  of  fracture  of  the  long  bones,  and  in  the  practice 
of  any  surgeon.  Xo  display  of  skill  will  absolutely  obviate 
non-union,  though  a  well  applied  retentive  apparatus,  after 
proper  adjustment  of  the  fragments,  is  believed  to  favor  con- 
solidation. 


FRACTURE    OF    THE    FEMUR    JUST    ABOVE    THE 

CONDYLES. 

Fractures  of  the  femur  above  the  condyles,  in  the  lower 
third  of  the  bone,  are  not  rare ;  they  are  generally  produced 
by  direct  causes,  though  indirect  violences,  as  heavy  falls  upon 


FIG.  82. 


the  feet,  may  break  the  femur  at  any  point. 
The  direction  of  the  line  of  separation  is 
rarely  transverse  or  fully  oblique.  Cases  are 
reported  in  which  the  line  of  separation  has 
been  nearly  transverse  ;  and  others  in  which 
the  obliquity  was  uniform  all  the  way 
through,  the  broken  surfaces  exhibiting  only 
minute  serrations.  The  circumference  of 
the  bone  increases  from  near  the  middle  of 
the  femur  to  the  widest  part  of  the  condyles, 
and  as  the  periphery  increases  the  cancellated 
tissue  augments,  making  so  much,  spongy 
material  in  the  lower  extremity  of  the  bone 
that  the  upper  fragment  may  be  driven  into 
it,  producing  a  state  of  impaction. 

In  a  simple  fracture  without  penetration 
or  impaction,  the  upper  fragment  usually 
occupies  a  position  in  front  of  the  lower, 
producing  shortening.  There  has  been  some 
speculation  in  regard  to  the  influences  which 
produce  this  position  of  the  fragments- 
The  action  of  the  gastrocnemius  upon  the 
condyles,  which  project  backwards,  forming 
levers  of  considerable  length,  is  the  principal  reason  why  the 
lower  fragment  is  tilted  so  powerfully  backwards.  It  is  no 
uncommon  occurrence  for  the  lower  end  of  the  upper  frag- 
ment to  encroach  upon  the  normal  position  of  the  patella,  and 
even  penetrate  the  synovial  cavity  beneath  that  bone,  making 


United  fracture  of  the 
femur  through  its  low- 
erthird,  witnoverlap- 
ping  and  angular  de- 
formity. 


208  FKACTUKES. 

a  complicated  injury  quite  serious  in  its  nature.  The  upper 
fragment  occasionally  gets  pushed  out  through  the  flesh,  pro- 
ducing a  compound  i'racture.  In  1805  I  was  called  to  Peter 
Mecklin,  a  German  laborer,  who  fell  from  a  high  hank  in  a 
quarry.  He  struck,  in  his  fall,  upon  a  projecting  rock,  and 
then  fell  several  feet  further  to  a  plane  landing.  His  com- 
rades found  him  with  the  broken  femur  pushed  through  the 
soft  structures  on  the  inside  of  the  knee.  I  saw  the  patient 
in  about  two  hours  after  the  injury,  and  observed  the  broken 
end  of  the  upper  fragment  still  protruding;  the  lower  frag- 
ment was  in  place  so  deeply  buried  in  flesh  that  its  fractured 
end  could  scarcely  be  outlined  by  manipulation.  After  strip- 
ping the  leg  of  pants  and  boot,  an  attempt  was  made,  by 
means  of  assistants,  to  extend  the  limb  sufficiently  to  allow 
the  protruding  bone  to  go  back  into  place,  but  such  efforts 
were  in  vain.  I  then  sent  for  chloroform,  and,  Avhen  the 
anaesthetic  arrived,  I  put  the  patient  profoundly  under  its  in- 
fluence, and  exerted  powerful  traction  upon  the  limb. 
This  course  proved  successful ;  the  bone  went  back  into 
place  in  apposition  with  the  other  fragment.  Although  the 
fracture  was  marked  with  considerable  obliquity,  the  consoli- 
dation took  place  with  not  more  than  a  half  inch  shortening. 
I  saw  one  case  of  compound  fracture  of  the  shaft  of  the  femur 
in  its  lower  third,  in  which  the  resistance  to  a  return  of  the 
fragment,  balked  the  efforts  of  two  quite  accomplished  sur- 
geons, in  their  efforts  at  reduction.  The  end  of  the  fragment 
was  finally  sawed  off,  to  allow  it  to  go  back  through  the  rent 
made  in  the  flesh.  It  is  possible  that  such  a  proceeding  might 
be  justifiable  in  extremely  rare  cases,  but  it  should  be  avoided 

if  possible. 

FIG.  83. 


—  • 

Fracture  of  the  femur  .just  nt>ove  the  condyles,  which  shows  th.-  N'lhl.  nry  of  the 
lower  fragment  to  encroach  ui»>ii  tin-  popliteal  space. 


The  broken  end  of  the  lower  fragment  1  »cing  tilted  back- 
ward by  the  action  of  the  gastrocnemius,  its  sharp  edge  may 
do  harm  to  the  vessels  and  nerves  of  the  popliteal  region. 
Paralysis  of  the  foot,  and  aneurism  of  the  artery,  are  said  to 


Or  THE  FEMUR.  209 

Lave  followed  such  an  injury.  Malgaigne  in  his  criticisms 
upon  what  Boyer  says  of  the  backward  movement  of  the 
lower  fragment,  declares  that  such  a  displacement  is  purely 
imaginary.  Hamilton  reports  a  case  treated  hy  a  surgeon  of 
Lockport,  X.  Y.,  in  which  parts  of  the  foot  sloughed  after 
fracture  of  the  femur  just  above  the  condyles ;  and  there 
get-mod  to  be  great  danger  of  death  to  the  leg.  All  the  dress- 
ings were  thrown  off,  and  efforts  made  to  restore  vitality  to 
the  leg.  The  limb  recovered  with  shortening,  and  the  loss  of 
the  toes  and  part  of  the  foot.  The  surgeon  at  length  sued 
the  father  of  the  patient  for  the  recovery  of  his  professional 
bill.  The  case  was  litigated  on  the  ground  that  the  dressings 
had  been  so  tight  as  to  impede  the  circulation  and  to  invite 
gangrene.  The  surgeon  got  judgment  in  his  favor  on  the  tes- 
timony of  several  distinguished  surgical  witnesses  who  de- 
clared that  the  sloughing  arose  from  injury  done  to  the  nerves 
by  the  lower  fragment  of  the  femur,  and  that  no  amount  of 
skill  and  and  attention  could  have  averted  the  evil. 

In  fractures  so  near  a  large  joint  the  dangers  are  greater 
than  when  the  femur  is  broken  at  a  distance  from  its  articula- 
tions. If  the  upper  fragment  is  dragged  down  against  the 
patella  the  injury  may  be  followed  by  a  high  grade  of  inflam- 
mation, and  anchylosis. 

The  symptoms  of  fracture  just  above  the  condyles,  are  gen- 
erally marked;  the  pain,  swelling,  inability  to  move  the  limb 
or  to  bear  weight  on  it,  necessaril}'  attend  the  accident.  Cre- 
pitus  may  be  produced  if  the  broken  surfaces  can  be  rubbed 
against  one  another,  but  in  the  event  of  much  overlapping  the 
grating  will  be  absent.  In  cases  of  many  hours  standing,  the 
swelling  obscures  the  characters  which  declare  themselves  so 
plainly  just  after  the  accident  occurs.  However,  the  angular 
deformity  which  is  very  great,  or  can  be  made  so  by  manipu- 
lating the  limb,  is  a  convincing  sign  of  fracture.  The  lateral 
mobility  which  does  not  belong  to  the  knee,  is  another  con- 
clusive diagnostic  sign. 

TREATMENT. — It  seems  unnecessary,  after  what  has  already 
been  said  concerning  the  treatment  of  fractures  of  the  shaft 
of  the  femur,  to  give  anything  more  than  general  directions 
for  the  management  of  fractures  just  above  the  condyles. 
The  reduction  can  sometimes  be  easiest  effected  by  flexing  the 
14 


210  FRACTURES. 

leg,  and  putting  the  arm  just  above  the  calf,  for  the 
of  making  extension.  A  straight  downward  pull  upon  the 
heel  and  foot  exerts  traction  upon  the  gastrocnemius,  therein' 
tending  to  tilt  the  broken  end  of  the  lower  fragment  back- 
wards. If  the  fragments  can  not  be  adjusted  without  the  in- 
fluence of  an  anaesthetic,  there  should  be  no  hesitancy  in  its 
early  employment. 

Cures  effected  with  the  aid  of  the  long  straight  splint  are 
not  very  satisfactory  ;  shortening  to  the  extent  of  one  or  two 
inches  being  a  common  result,  to  say  nothing  of  other  glaring 
defects.  The  long  straight  splint,  for  "the  purposes  ot  effect- 
ing extension  and  counter-extension,  has  man}7  advocates,  but 
it  finds  little  favor  with  me  in  the  treatment  of  such  injuries  ; 
the  double  inclined  plane  apparatus  does  better,  yet  it  has  its 
objections.  It  is  better  to  envelope  the  thigh  with  retentive 
splints,  the  pieces  of  lath  or  thin  board  being  laid  longitudi- 
nally with  the  lirnb,  across  the  fractured  line  in  the  bone,  where 
they  are  to  be  bound  in  place  with  tapes  and  bandages.  Ex- 
tension can  be  made  from  the  leg  and  ankle  by  means  of  ad- 
hesive strips,  using  the  weight  and  pulley,  or  raising  the  foot 
of  the  bed  on  blocks  after  making  the  limb  fast  to  it.  To 
relax  the  muscles  of  the  thigh  and  leg  a  large  sand  bag  or 
cushion  is  to  be  placed  under  the  knee  to  keep  it  permanently 
flexed.  The  limb  may  also  be  bolstered  up  and  kept  in  a 
straight  line  by  means  of  several  sand  bags  placed  along  its 
sides  at  places  where  support  is  needed.  Whatever  be  the 
dressing  applied,  it  should  be  employed  for  six  or  eight  weeks, 
and  even  longer  in  old  subjects.  After  the  extending  and  re- 
tentive appliances  have  been  laid  aside,  no  weight  should  be 
borne  upon  the  limb  until  several  weeks  more  have  elapsed 
lest  overlapping  and  angular  deformity  take  place  from  yield- 
ing of  the  new  formed  callus  or  uniting  medium.  During 
this  convalescing  interval  gentle  motion  should  be  kept  up  at 
the  knee  to  obviate  stiffness  and  anchylosis,  and  the  limb  may 
be  rubbed  with  stimulating  liniments  to  restore  the  normal 
activity  of  the  muscles.  Until  consolidation  takes  place  and 
while  the  retentive  dressings  are  in  use,  measurements  and 
comparisons  of  the  two  limbs  should  be  often  made.  The 
general  contour  and  condition  of  the  leg  should  be  observed 
at  every  visit,  and  any  deviation  or  defect  guarded  against  by 
re-adjustments  of  the  appliances,  or  by  changing  the  entire 


OF  THE  FEMUR.  211 

plan  of  treatment  if  deemed  necessary.  The  state  of  the  cir- 
culation in  the  foot,  and  the  condition  of  the  skin  where 
dressings  bear  heavily,  must  not  be  neglected.  A  tight  wrap- 
ping  can  generally  be  loosened  by  cutting  part  way  through  a 
few  turns  of  the  bandage ;  and  a  loose  dressing  may  be  made 
tighter  by  the  application  of  a  few  additional  strips  employed 
as  ties.  The  surgical  attendant  must  bear  in  mind  that  the 
tendency  of  a  broken  thigh  is  to  deformity,  and  that  the  per- 
verse inclination  must  be  constantly  and  efficiently  opposed, 
leaving  nothing  to  "  luck"  or  hazard. 


FRACTURE  OF  THE  COXDYLES  OF  THE  FEMUR. 

Fracture  of  one  or  both  condyles  is,  fortunately,  a  rare  acci- 
dent, for  the  injury  is  attended  with  dangers  of  a  serious 
nature.  The  knee-joint  is  exceedingly  intractable  when  sub- 
jected to  the  influence  of  disordered  action.  Effusions  into 
the  articular  structures  are  attended  with  great  distress  and 
constitutional  disturbance. 

The  force  which  breaks  a  condyle  of  the  femur  may  be 
direct,  as  when  a  heavy  weight  falls  upon  the  knee ;  or  it  may^ 
be  indirect,  as  when  a  person  in  falling  strikes  in  such  a  way 
as  to  have  the  violence  communicated  to  the  side  of  the  femur 
which  did  not  receive  the  primary  impression.  The  disen- 
gaged fragment  may  include  the  articular  surface  of  the  inner 
or  outer  condyle  and  four  or  five  inches  of  the  condyloid 
ridge,  terminating  in  a  point  at  its  upper  extremity.  One 
condyle  is  broken  about  as  often  as  the  other,  though  the 
inner  is  less  protected  from  direct  violence. 

The  muscular  forces  exerted  upon,  a  broken  condyle  are  an- 
tagonized to  a  great  extent ;  the  two  vasti  pull  upwards  and 
the  gastrocnemius  downwards.  The  lateral  and  crucial  liga- 
ments are  opposed  to  much  displacement,  unless  both  condyles 
give  way,  allowing  the  central  wedge-shaped  shaft  in  its  course 
do\vnwards,  to  force  them  asunder. 

I  have  the  specimen  of  a  fractured  internal  condyle  which 
was  taken  from  the  leg  of  Thomas  R.,  a  laborer,  who  lost  his 
life  by  falling  to  the  bottom  of  a  well,  which  was  being  dug. 
In  the  descent  the  knee  hit  against  the  edge  of  a  heavy  tub 
attached  to  a  windlass  used  in  raising  the  earth  which  was 


212  FRACTURES.     , 

being  excavated.     The  line  of  separation  in  the  broken  bone 
begins  near  the  centre  of  the  articular  concavity  at  the  lower 
end  of  the  bone,  and  extends  upwards  and  inwards  about  five 
„      Q.         inches,  terminating   in   the   condyloid    ridge. 
The  broken  surfaces  are  rough  with  the  usual 
spiculse,  but   bear   no    marked   irregularities. 
The  separated  coudyle  was  not  displaced  by 
the  force  which  produced  the  fracture. 

The  symptoms  of  a  broken  coudyle  are  not 
marked  and  palpably  distinctive,  though  the 
diagnosis  can  be  determined  by  a  careful  man- 

Practure  of  the  inter-    .  ..  ,.     ,-,  ^^^  •  ^^• 

nai  condyie  of  the  ipulation  or  the  parts.  Ihe  pain,  swelling, 
and  inability  to  bear  weight  on  the  limb,  are 
features  that  could  not  well  be  absent.  The  joint  in  its  nor- 
mal state  admits  only  of  the  hinge  motion,  backward  and 
forward,  but  after  fracture  of  either  condyie  the  lateral  motion 
which  can  be  imparted  to  the  joint  clearly  indicates  the  nature 
of  the  injury.  The  separation  of  the  epiphyseal  extremity  of 
the  bone  in  a  young  subject,  might  obscure  the  difficulty,  as 
might  a  transverse  fracture  of  the  femur  close  above  the  con- 
dyles.  Crepitus  can  be  elicited  in  either  kind  of  fracture, 
therefore  the  existence  of  that  sign  would  not  throw  much 
light  upon  a  doubtful  case.  However,  when  a  cond}?le  is  sep- 
arated from  the  rest  of  the  bone  the  disengaged  fragment  can 
be  grasped,  and  moved  independently  of  the  rest  of  the  femur, 
and  the  movement  is  attended  with  a  crepitating  sound  that 
corresponds  with  the  motion.  The  increased  width  of  the 
joint  is  another  sign  of  some  value,  and  should  not  be  neg- 
Fio  85  lected.  If  the  fracture  be  caused  by  the  pas- 
sage of  a  wheel  over  the  joint,  or  by  any  vio- 
lence of  a  crushing  character,  the  lower  ex- 
tremity of  the  femur  may  be  broken  into  sev- 
eral pieces,  some  of  which  may  be  so  isolated 
from  nourishing  tissues  that  they  will  become 
foreign  bodies,  creating  grave  local  and  general 
disturbance.  The  suppuration  attendant  upon 
F condytls  of fthe°fei  tue  discharge  of  such  pieces  of  bone,  exhausts 
the  patient,  and  occasionally  necessitates  am- 
putation to  save  life.  The  case  of  a  boy  with  a  compound 
fracture,  is  reported  in  Braithwaite 's  Retrospect,  Vol.  XV.,  in 
which  a  good  recovery  was  made,  though  a  piece  of  the  ex- 


OF  THE  FEMUR.  213 

ternal  condyle  worked  its  way  out  in  the  course  of  three  or 
four  mouths  from  the  reception  of  the  accideut. 

TREATMENT. — The  gravity  of  the  lesion  requires  more  pa- 
tience and  skill  to  combat  inflammation  and  to  avoid  the 
necessities  of  amputation  than  to  adjust  the  fragments  and  to 
retain  them  quietly  in  place.  Anodynes  and  cooling  lotions 
mufct  be  topically  used,  and  opiates  administered  internally. 
The  employment  of  the  long  splint,  which  necessitates  the 
straight  attitude,  is  out  of  the  question.  If  only  one  condyle 
is  broken,  and  there  is  no  displacement,  the  knee  should  be 
moderately  flexed  by  being  placed  on  a  sand  bag.  If  the  foot 
is  forcibly  inclined  to  eversion,  the  tendency  may  be  counter- 
acted by  other  bags  arranged  along  the  outside  of  the  limb. 

In  the  event  of  a  double  fracture,  both  condyles  being  sep- 
arated from  the  shaft,  there  is  considerable  shortening  to  be 
overcome.  This  can  not  be  accomplished  by  using  the  straight 
apparatus  of  Desault,  or  the  double-inclined  plane  splint  in 
common  use.  A  moderate  degree  of  flexion  is  one  of  great- 
est ease  and  repose ;  and  should  anchylosis  take  place  the 
limb  is  the  most  serviceable  in  that  position.  The  use  of  ad- 
hesive plaster  repeatedly  described,  is  the  easiest  method  of  ap- 
plying extending  force,  and  the  inclination  of  the  body  in  the 
opposite  direction,  produced  by  elevating  the  foot  of  the  bed, 
is  the  most  comfortable  manner  of  obtaining  counter-exten- 
sion. If  the  knee  be  too  wide,  a  leather  or  pasteboard  splint 
should  be  bound  around  the  limb,  enveloping  the  joint  and  a 
few  inches  of  the  leg  and  thigh.  Should  the  soft  parts  be 
much  bruised,  no  stiff  dressing  can  be  endured.  As  soon, 

FIG.  86. 


A  woven  wire  appliance  to  support  the  log  nftcr  r'nK-tinv.-  near  the  knee-joint. 

however,  as  the  flesh  wounds  have  sufficiently  healed  to  re- 
ceive a  slightly  comprising  support,  it  may  be  employed  to 
advantage. 

Passive  motion   should  be  begun  by  the  thirtieth  day  in  a, 
gentle  manner  at  first,  and  kept  up  for  months  or   until  the 


214  FRACTURES. 

functions  of  the  joint  are  fully  restored,  or  recovered  as  far 
as  practicable.  Passive  motion  is  as  essential  during  the 
period  of  convalescence  after  fracture  of  a  femoral  as  in  the 
final  treatment  of  a  humeral  condjle,  but  the  knee  will  not 
endure  the  rough  usage  that  can  be  imposed  on  the  elbow. 

In  the  earlier  part  of  the  treatment  a  tendency  to  deflection 
to  the  right  or  left  is  to  be  guarded  against  as  well  as  shorten- 
ing. The  leather  or  pasteboard  splints  if  allowed  to  extend 
above  and  below  the  knee,  and  if  kept  snugly  bound  in  place 
with  a  bandage  or  multiple  ties,  operate  against  lateral  defor- 
mity, and  the  extending  and  counter-extending  forces  resist 
the  overlapping.  Eversion  of  the  foot  and  limb  is  prevented 
by  the  use  of  sand  bags.  Moderate  flexion  of  the  knee  re- 
laxes the  muscles  of  the  leg.  The  ordinary  double  inclined 
plane  fracture  box  or  appliance  for  the  leg,  constitutes  a  very 
serviceable  dressing  for  treating  a  femur  broken  at  the  con- 
dyles.  In  a  case  of  comminuted  fracture  of  the  lower  ex- 
tremity of  the  femur,  including  a  severance  of  both  condyles, 
which  recently  came  under  the  treatment  of  Prs.  Potter  and 
Clarke,  of  Hamilton,  O.,  the  double  inclined  plane  apparatus 
was  used  ;  and  the  result  could  not  be  more  satisfactory.  By 
the  courtesy  of  the  surgical  attendants  I  was  invited  to  see 
the  case  under  treatment,  and  was  pleased  with  the  skillful 
management  of  the  means  employed. 


CHAPTER    XXVI. 
FRACTURE  OF  THE  PATELLA. 


The  patella  is  much  exposed  to  direct  violence,  but  the 
facility  with  which  it  slides  in  various  directions,  saves  it  from 
fracture.  Indirect  violence  cannot  reach  it;  but  muscular 
action  exerts  a  powerful  influence  upon  it.  The  size  and 
shape  of  the  bone  contribute  to  its  immunity  from  fracture. 

The  patella  is  a  sesamoid  growth  in  the  tendon  of  the 
quadriceps  extensor  cruris  muscle,  and  plays  the  part  of  a  ful- 
crum and  lever  at  the  same  time.  In  the  former  office  it  can 
not  be  crushed  by  muscular  action  ;  but  in  the  latter  capacity 
it  may  be  snapped,  the  fracture  running  through  the  bone 
transversely.  A  blow  may  break  it  longitudinally,  or  crack 
it  into  several  pieces.  The  patella  is  broken  by  muscular 
force  more  frequently  than  any  other  bone  in  the  body. 
When  the  knee  is  slightly  bent  the  bone  is  supported  upon  the 
condyles  of  the  femur  on  its  transverse  axis  only,  becoming 
wholly  a  lever,  and  losing  its  character  of  fulcrum.  Its  upper 
edge  is  then  elevated  and  unsupported,  as  well  as  its  lower, 
which  is  held  rigidly  in  place  by  the  ligamentum  patellae. 
Under  these  circumstances  the  rectus  femoris  and  its  associate 
muscles,  no  longer  act  in  a  direction  corresponding  with  the 
longitudinal  axis  of  the  bone,  but  nearly  at  right  angles  with 
it.  In  a  violent  effort  to  save  the  body  from  falling  back- 
wards, the  bone  may  snap  transversely.  In  one  instance  I 
knew  a  boy  to  break  one  of  his  patellae  while  jumping  a  wide 
•ditch.  As  he  landed  the  body  dropped  down  so  as  to  bring 
the  knee  into  extreme  flexion,  and  he  says  the  knee-pan 
snapped  at  that  time.  In  that  instance  the  conditions  were 
not  favorable  to  a  fracture  of  the  patella,  for  its  position  was 
such  when  the  knee  was  excessively  flexed,  that  its  centre  was 
unsupported,  and  the  force  acted  in  the  direction  of  the  ver- 
tical axis  of  the  bone,  and  no  leverage  could  be  obtained  upon 

(2151 


216  FRACTUHES. 

it.  In  order  that  the  patella  maybe  placed  in  the  most  favor- 
able position  for  tlie  muscular  force  to,act  upon  it,  the  knee 
must  be  only  moderately  flexed;  then  the  ligainentum  patellre 
holds  the  bone  poised  on  its  centre,  between  the  coudyles  of 
the  femur,  and  the  muscles  act  upon  its  upper  edge.  Extreme 
force  is  not  brought  upon  the  patella  when  it  plays  the  part 
of  a  lever,  except  a  person  in  walking,  slips  with  one  or  both 
feet,  and  ill  an  effort  to  resist  a  fall,  or  to  recover  an  equipoise 
of  the  body,  he  attempts  to  straighten  the  knee  which,  has  be- 
come partially  flexed.  It  is  just  at  this  time  that  the  patella  is 
placed  under  the  most  favorable  conditions  for  tlie  muscles  to 
act  upon  it;  and  it  is  at  this  moment  that  the  muscles  act 
suddenly  in  the  most  powerful  manner.  While  the  knee  is 
bending  it  is  instantly  checked  in  its  course  of  flexion,  and 
changed  to  a  state  of  extension.  If  the  patella  be  poised  on 
its  articular  apex,  its  integrity  is  severely  tested;  but  if  the 
leg  be  nearly  straight  or  extremely  flexed,  the  force  acts  in  a 
straight  line  with  the  bone,  and  the  tendon  above  or  below  the 
bone  is  put  to  a  dangerous  test.  The  patella  is  ordinarily 
strong  enough  to  resist  any  muscular  force  that  can  be  brought 
to  bear  upon  it,  but,  as  has  been  stated,  if  it  be  caught  in  a 
poised  position  between  the  condyles  when  great  and  sudden 
power  is  exerted  on  the  part  of  the  muscles,  the  bone  is  put 
to  a  disadvantageous  strain,  and  may  snap,  as  a  short  stick  is 
made  to  break  across  the  knee  by  the  power  of  the  hands. 
A  person  in  going  down  stairs  may  catch  the  heel  or  par- 
tially stumble,  and  in  the  effort  to  shun  a  fall  receive  a  frac- 
tured patella.  By  far  the  most  common  cause 
"Rio  87 

of  a  broken  patella  is  direct  violence  ;  the  kick 

of  a  horse,  the  hitting  of  the  bone  against 
some  solid  substance  in  a  fall,  the  blow  of  an 
axe,  hammer,  or  implement  violently  hurled 
by  moving  machinery,  are  all  well  known 
causes. 
Transverse  fracture  of  rf^e  symptoms  of  transverse  fracture  of  the 

the  patella.  * 

patella  are  prominent  and  unmistakable.  The 
patient  feels  the  sudden  separation  of  the  bone,  and  generally 
declares  that  he  heard  the  snap  attending  it.  He  is  unable  to 
extend  or  advance  the  leg,  and  seems  to  be'  instinctively  con- 
scious of  the  nature  of  the  injury.  The  lower  fragment 
remains  in  place,  being  held  there  by  the  ligamentum  patella  ; 


OF  THE  PATELLA.  217 

but  the  upper  fragment  is  drawn  upward  sometimes  to  'the 
extent  of  several  inches — generally  an  inch  or  two.  The 
upper  fragment  can  be  found  as  the  hand  is  slid  down  the 
thigh  near  the  knee,  and  the  fingers  tind  a  yielding  depres- 
sion between  the  fragments.  Just  above  the  lower  fragment, 
the  knee,  when.the  leg  is  hVxed,  evidently  has  lost  something 
which  normally  produces  a  fullness  there. 

No  crepitus  need  be  expected  unless  the  leg  be  extended 
and  the  quadriceps  be  pressed  powerfully  downwards,  so  as 
to  allow  the  fragments  to  reach  each  other :  if  once  brought 
in  contact  by  the  above  means  the  broken  surfaces  may  be 
made  to  grate  against  each  other. 

Considerable  swelling  takes  place  from  effusions  of  lymph 
and  extravasation  of  blood.  If  the  limb  is  not  seen  for  sev- 
eral hours  succeeding  the  accident,  the  swelling  will  mask 
some  of  the  prominent  symptoms,  yet  the  fingers  firmly 
pressed  along  the  anterior  aspect  of  the  limb  in  the  vicinity 
of  the  joint,  will  discover  the  upper  fragment  dragged  up- 
ward, and  the  abnormal  depression  between  the  pieces.  The 
furrow  between  the  condyles  will  also  be  recognized  if  the 
lingers  are  pressed  into  that  snlcus. 

In  an  oblique  fracture  of  the  patella  the  signs  of  the  lesion 
will  be  as  apparent  as  in  a  transverse  separation.  In  multiple 
or  stellate  fracture  the  fragments  may  not  be  displaced,  but 
all  will  be  held  in  position  by  the  tendinous  surroundings. 
In  such  a  case  crepitation  could  be  readily  elicited,  and  move- 
ments of  the  limb  would  cause  sufficient  irregularity  of  the 
pieces  to  be  discoverable  with  the  aid  of  the  fingers.  Flexion 
of  the  limb  would  produce  separation  of  some  of  the  frag- 
ments, as  the  quadriceps  must  take  one  or  more  pieces  of 
bone  along  with  it  as  contraction  of  the  muscles  ensues. 

In  a  longitudinal  fracture  of  the  patella  there  may  be  lateral 
separation  of  the  fragments,  though  the  beveled  and  project- 
ing condvles  on  each  side  tend  to  keep  them  in  place.  The 
action  of  the  vasti  muscles,  pulling  in  opposite  directions,  the 
force  being  from  the  centre  towards  the  sides  of  the  limb, 
may  separate  the  fragments  when  the  leg  is  flexed. 

One  of  the  peculiarities  gf  a  fractured  patella  is  that  the 
fragments  unite  very  frequently  with  fibrous  material,  and 
rarely  consolidate  with  bony  matter.  The  length  of  the 
fibrous  bands  depends  upon  the  distance  existing  between  the 


218  FRACTURES. 

fragments  during  the  healing  process.     It  is  not  uncommon 
to  find  the  fibrous  connection  nearly  an  inch  in  length.     In 
tlie  case  of  Mary  Adams,  of  Covington,  Ky., 
who  broke  the  right  patella  transversely  by  a 
tumble  on  some  out-door  steps,   [   secured  a 
very  short    ligamentous    union,  so    that    she 
walked  well  at  first,  but  in  less  than  a  year  the 
connecting  band  had  stretched,  torn,  or  yielded, 
so   that  there   were  two   inches  between  the 
fragments  when  the  leg  was  forcibly  flexed. 
^r-  Coale  presented  to  the  Boston  Society  for 
[™tei?™  °f  the    Medical  Improvement,  a  specimen  of  a  frac- 
tured  patella  taken   from   a  man    sixty-five 
years  old,  the  fracture  having  occurred  ten  years  before.     Dr. 
C.   reports  that  the  fragments  at  first  were  so  closely  united 
that  no  separation  between  them  could  be  discovered  ;  but 
subsequently  they  became  disjoined  at  their  outer  edges  one 
inch,  and  at  their  inner  edges  very  much  less. 

TREATMENT. — The  sooner  the  limb  is  properly  dressed,  after 
fracture  of  the  patella,  the  easier  it  will  be  to  accomplish  the 
chief  object  of  the  treatment.  The  muscles  attached  to  the 
patella  are  so  powerful  that  their  contraction  goes  on  from 
day  to  day  until  at  the  end  of  a  week  or  two  a  space  of  two 
or  three  inches  between  the  fragments  exists,  though  the  sep- 
aration of  the  pieces  of  bone  may  have  been  less  than  an  inch 
at  first.  Immediately  succeeding  the  fracture  the  two  por- 
tions of  bone  can  be  easily  brought  into  contact,  whereas  in 
the  course  of  a  few  days  the  muscles  have  become  so  much 
contracted  and  accommodated,  as  it  were,  to  their  new  po-i- 
tion,  that  it  is  often  quite  impossible  to  elongate  them  suffi- 
ciently to  bring  the  piece  of  bone  connected  with  them  down 
far  enough  to  meet  the  lower  portion:  the  consequence  of 
which  is,  that  direct  apposition  and  consolidation  are  never 
obtained,  but  a  kind  of  ligamentous  or  fibrous  union  is  the 
result.  It  is  generally  believed  among  experienced  surgeons 
that  the  great  rareness  of  bony  union  in  transverse  fractures- 
of  the  patella  must  be  owing  simply  to  the  difficulty  of  keep- 
ing the  fragments  in  sufficient  !v.  dose  apposition  ;  if  contact 
of  the  broken  surfaces  could  be  produced  and  steadily  main- 
tained for  several  weeks,  bony  union  might  be  expected  as  in 
other  fractures. 


OF  THE  PATELLA. 


219 


A  modification  of  the  dressing  employed  by  Mr.  Cooper  is 
represented  in  the  accompanying  diagram,  and  maybe  applied 
as  follows  ;  carry  a  circular  bandage  from  the  toes  to  the  knee, 
binding  two  strips  of  uniting  bandage  which  are  laid  on  the 
sides  of  the  leg,  the  upper  ends  being  left  free  for  tying  above 
the  upper  fragment  when  it  is  bandaged  down  into  place. 
Another  roller  is  to  be  applied,  beginning  at  the  upper  part 


Circular  bandnges  nbove  and  below  the  knee  serve  to  hold  firmly  in  plnce  two  sets  of  uniting 
tapes  which  are  to  be  tied  above  and  below  the  fragments  of  the  patella. 

of  the  thigh  and  bandaging  downward  while  an  assistant  with 
both  hands  near  the  knee  pulls  powerfully  upon  the  quadriceps. 
The  bandage  secures  and  maintains  the  stretching  and  exten- 
sion applied  by  the  assistant.  Two  strips  of  strong  cloth  are 
to  be  laid  upon  the  sides  of  the  thigh,  and  covered  by  the 
spiral  bandage,  as  was  done  below  the  knee.  The  free  ends 
of  the  uniting  bandages  are  to  be  tied  above  and  below  the 
fragments,  a  compress  being  placed  where  the  knots  are  to 
rest.  If  the  uniting  strips  be  tied  snugly,  they  exert  a  pow- 
erful influence  towards  bringing  the  fragments  in  contact. 
To  finish  the  dressing  a  compress  may  be  laid  on  the  patella, 
and  held  in  place  by  a  few  turns  of  a  third  roller,  which  also 
covers  in  the  space  between  the  other  bandages  and  secures 
equal  pressure  the  whole  length  of  the  limb.  A  long  splint 
may  be  bound  to  the  posterior  aspect  of  the  leg  to  prevent  the 
slightest  degree  of  flexion  at  the  knee.  The  rectus  femoris  is 
freed  from  tension  by  elevating  the  leg  on  cushions  or  other 
supports. 

The  dressing  just  described  operates  very  well  when  the 
bandages  wholly  prevent  the  ties  from  slipping,  but  practically 
it  is  found  that  they  will  not.  To  obviate  that  serious  defect 
Dr.  Sanborn,  of  Lowell,  Mass.,  devised  a  modification  of  the 
old  plan,  using  adhesive  strips  in  place  of  the  ties  or  uniting 
bandages.  He  recommends  a  strip  of  ordinary  adhesive  plas- 


220  FRACTURES. 

ter  four  feet  long  and  two  and  a  half  inches  wide  to  be  applied 
to  the  anterior  aspect  of  the  limb  from  the  upper  portion  of 
the  thigh  to  the  middle  of  the  leg,  leaving  a  free  loop  at  the 
knee  for  purposes  presently  to  be  explained.  The  ends  of 
the  strip  to  within  a  few  inches  of  the  knee,  are  bound  in 
place  by  a  couple  of  rollers — one  for  the  foot  and  leg,  as  in 
Cooper's  dressing,  and  the  other  for  the  thigh.  A  hard  roller 
compress  is  placed  immediately  above  the  upper  fragment, 
and  then  a  small  stick,  as  a  twister,  is  put  through  the  loop, 
and  revolved  until  great  power  is  brought  TO  bear  upon  the 
parts  to  which  the  adhesive  strip  is  attached.  This  is  an 
efficient  and  easily  applied  apparatus,  and  good  results  may  be 
obtained  from  its  use.  I  have  employed  it  in  one  instance, 
with  the  addition  of  a  single  inclined  plane  to  elevate  the 
foot,  and  secured  a  bony  union  of  the  fragments. 

If  the  fracture  occurs  from  direct  violence  tin-re  will  be 
danger  of  a  high  grade  of  inflammation  and  anchylosis. 
Cooling  and  anodyne  lotions  that  will  not  interfere  with  the 
dressings,  should  be  freely  employed  during  the  early  part  of 
the  treatment.  At  the  expiration  of  four  or  live  weeks  from 
the  reception  of  the  injury,  passive  motion  is  to  be  instituted. 
and  kept  up  until  the  functions  of  the  joint  are  restored. 

In  a  case  of  vertical  or  longitudinal  fracture  the  knee-joint 
should  be  enveloped  in  strips  of  adhesive  plaster  to  retain  the 
fragments  steadily  in  juxtaposition.  The  tendency  is  to  lat- 
eral displacement  of  the  fragments  in  a  moderate  degree,  and 
the  adhesive  strips  are  used  to  counteract  it.  Osseous  union 
is  pretty  certain  to  follow  this  treatment.  Arthritis  and  an- 
chylosis are  the  most  dangerous  conditions  to  be  guarded 
against. 

I  have  never  met  with  a  case  of  a  recurrence  of  the  lesion 
after  fracture  of  the  patella,  but  such  accidents  are  reported. 
I  am  inclined  to  think  that  there  was  no  bony  union  in  such 
cases,  and  that  the  "  recurrence  ''  was  merely  a  tearing  of  the 
fibrous  connection. 

It  is  rare  for  a  patient  to  recover  entirely  after  having  sus- 
tained fracture  of  the  patella.  In  the  event  of  fibrous  union 
of  the  fragments  the  power  of  extending  the  leg  is  impaired: 
and  bony  union  is  generally  followed  by  excesses  of  callus 
that  impede  the  motions  of  the  joint.  A  complete  restora- 
tion of  all  the  functions  of  the  limb  is  a  fortunate  issue. 


CHAPTER    XXYII. 
FRACTURES    OF    THE    LEG 


The  bones  of  the  leg  are  parallel  in  direction,  but  quite  dif- 
ferent in  size,  shape,  and  function  ;  the  tibia  is  large,  and  by 
its  broad  articulation  with  the  femur  and  tarsus,  is  evidently 
designed  to  support  the  weight  of  the  body  ;  the  fibula  is 
small,  and  is  destined  not  to  sustain  weight,  but  to  give  at- 
tachment to  many  muscles,  and  its  lower  end  contributes  to 
the  formation  of  the  ankle  joint.  The  tibia  has  broad  articu- 
lar extremities  and  a  triangular  shaft;  the  fibula  has  moderate 
sized  extremities,  and  a  slender  prismatic  shaft.  The  two 
bones  have  quite  different  offices  to  perform,  yet  they  are  so 
intimately  associated  in  their  anatomical  relations  that  both 
are  more  frequently  broken  by  a  single  accident  than  either 
is  fractured  separately.  A  force  sufficient  to  break  the  tibia 
is  generally  powerful  enough  to  reach  the  fibula  and  to  break 
it  also. 

The  tibia  being  thinly  covered,  is  exposed  to  direct  violence, 
and  peculiarly  liable  to  compound  fracture;  the  fibula  is 
pretty  well  buried  in  soft  tissues,  and  when  broken,  its  frag- 
ments rarely  puncture  the  skin. 

The  causes  of  fracture  of  the  leg  are  either  direct,  as  the 
passage  of  a  wheel  over  the  limb  ;  or  indirect,  as  in  landing 
heavily  upon  the  feet,  from  a  jump  or  fall.  The  relative  fre- 
quency of  these  causes  in  the  production  of  fracture  has  been 
variously  estimated  by  different  authors.  Hamilton  considers 
that  four-fifths  of  them  come  from  direct  violence,  while  Mal- 
gaigne  found  that  in  sixty-seven  fractures  of  the  leg  observed 
by  him,  thirty-six  were  produced  by  direct,  and  thirty-one  by 
indirect  violence.  There  are  some  parts  of  the  tibia,  as  the 
head  and  lower  extremity,  that  rarely  yield  from  the  influence 
of  an  indirect  force  ;  but  when  a  person  in  a  jump  or  fall 

(221) 


222 


FRACTURES. 


FIQ.  90. 


comes  to  the  ground  on  his  feet,  the  force  is  likely  to  net  ob- 
liquely upon  the  shaft  of  the  bone,  and  snap  it  across.  Direct 
forces  may  fracture  any  part  of  the  bone,  for  all  parts  are  ox- 
posed  to  the  influence  of  kicks,  blows,  projectiles,  falling 
bodies,  and  moving  machinery. 

Both  bones  of  the  leg  may  be  broken,  as  has  just  been 
stated,  at  the  same  time,  or  by  the  same  accident;  if  the  vio- 
lence be  direct  the  fracture  may  be  on  the  same  line  in  the 
two  bones  ;  if  indirect,  the  tibia  is  liable  to  yield  in  its  lower 
third,  and  the  fibula  somewhere  above  its  middle.  Peculiar 

circumstances  may  allow  the  indi- 
rect force  to  break  the  two  bones  in 
the  same  line  ;  and  others  may  occur 
which  cause  the  direct  force  to  break 
each  at  different  points. 

When  the  indirect  force  acts,  the 
fibula  must  almost  always  break  a  Her 
the  fracture  of  the  tibia  has  taken  place. 
for  the  force  continues  ou upwards  and 
comes  upon  the  fibula  with  the  addi- 
tional weight  of  the  body  of  the  person 
which  is  no  longer  supported  by  the 
tibia,  consequently  the  whole  stre>> 
tells  on  the  slender  fibula  above  where 
the  other  bone  gave  way,  producing  a 
fracture  in  its  upper  third.  A  violent 
and  sudden  twist  of  the  ankle,  which 
is  force  indirectly  applied,  may  cause 
fracture  of  both  bones  just  above  the  joint,  the  line  of  separa- 
tion being  nearly  on  the  same  level. 

It  is  rare  to  find  the  fibula  broken  below  the  point  of  frac- 
ture in  the  tibia,  even  though  direct  force  has  caused  the  in- 
jury. If  the  leg  be  broken  by  a  wheel  passing  over  it  ob- 
liquely, the  fibula  being  struck  at  a  point  lower  down  than 
the  tibia  is  hit,  the  line  of  separation  in  the  two  bones  must 
correspond  with  the  points  subjected  to  violence. 

The  direction  the  fracture  takes  is  much  the  same  it  is  in 
the  long  bones  generally  :  if  the  force  be  indirect,  the  oblique 
course  prevails;  if  direct,  the  transverse.  In  most  instances 
the  line  of  separation  is  irregular,  but  inclining  to  the  oblique. 
The  tibia  is  most  liable  to  exhibit  a  predominance  of  obliquity 


Fracture  of  both  bones  of  tho 
leg ;  the  fibula  through  its  u  p- 
per,  and  the  tibia  through  its 
lower  third. 


OF  THE  LEG. 


223 


FIG.  91. 


in  the  line  of  its  fractures;  and  the  fibula  shows  :i  tendency 
to  the  transverse  direction  in  the  line  of  its  separations. 

Displacements  may  take  place  as  in  fractures  of  other  hones, 
and  from  similar  causes;  in  transverse  fractures  the  fragments 
may  not  become  disengaged,  at  least  there  is  less  tendency  to 
displacement;  in  oblique  fractures,  on  the  contrary,  there  is 
nearly  always  overlapping,  sometimes  to  a  considerable  ex- 
tent, as  when  the  fracture  is  caused  by  a  fall  on  the  feet  from 
a  height,  for  the  force  being  more  than  sufficient  to  break  the 
bones,  continues  to  act,  and  so  displaces  them.  Combined 
with  this  there  is  usually  some  rotatory  displacement,  due 
partly  to  the  force  received  and  partly  to  muscular  action. 

The  signs  of  fracture  in  the  bones  of  the  leg,  are  generally 
well  marked,  though  not  always  comprehended  in  their 
utmost  significance.  In  other  words,  it  may  be  plain  that  a 
fracture  exists,  but  it  is  not  generally  an  easy  matter  to  deter- 
mine whether  one  bone  is  broken  or 
both,  and  what  is  the  direction  of 
the  fracture,  the  extent  of  the  injury 
in  all  its  bearings  and  complications, 
and  what  obstacles  are  to  be  over- 
come in  the  treatment.  The  crepi- 
tus,  mobility,  and  deformity  are 
commonly  detected  upon  the  slight- 
est examination.  The  tibia  is  so 
near  the  skin  that  the  smallest 
amount  of  displacement  is  readily 
detected  by  passing  the  fingers  along 
the  course  of  the  bone  ;  the  fibula 
is  more  deeply  covered,  yet  thorough 
manipulation  can  not  fail  to  discover 
the  place  where  the  separation  ex- 
ists. The  surgeon,  in  examining  a 
leg  which  has  sustained  a  fracture, 
should  not  be  content  with  the  discovery  of  a  break  in  one 
bone,  but  he  should  carefully  scrutinize  the  other.  It  has 
been  already  stated  that  a  fracture  of  both  bones  in  a  single 
accident,  is  more  common  than  the  fracture  of  one  bone 
singly,  therefore  in  a  given  case  the  probabilities  are  always 
in  favor  of  both  bones  having  been  broken.  In  the  treatment 
of  fractures  of  the  leg  it  is  of  the  utmost  importance  to  de- 


Fracture  of  both  bones  of  the  leg  on 
nearly  the  same  plane,  the  result  of 
direct  violence. 


224  FKACTUIIES. 

termine  whether  one  boue  is  broken  or  two;  if  only  one  bone 
be  broken  there  may  be  a  rotatory  or  twisting-  kind  of  defor- 
mity, but  there  can  be  no  serious  degree  of  shortening ;  if  both 
bo*nes  be  broken,  and  the  surgeon  discover  a  fracture  in  one 
alone,  and  treat  the  injury  according  to  his  fault}-  diagnosis, 
the  most  serious  consequences  are  sure  to  be  the  result. 

In  considering  the  displacement  that  occurs  in  fractures  of 
both  bones  of  the  leg,  it  may  be  easy  to  determine,  for  in- 
stance, that  the  upper  fragment  of  the  tibia  takes  a  position 
in  front  of  the  lower  fragment;  but  to  decide  upon  the  rela- 
tive positions  of  the  fragments  of  the  tibula  may  he  attended 
with  some  difficulty.  The  force  that  displaces  the  fragments 
may  be  of  two  kinds, — it  may  come  from  muscular  action 
pulling  the  lower  fragment  above  the  upper;  or  it  may  be  that 
which  causes  the  fracture,  driving  one  portion  of  bone  from 
its  contact  with  the  other  after  the  break  lias  occurred.  It  is 
more  probable  that  the  same  force  would  go  on  acting  after  it 
has  fractured  the  bones,  than  it  should  cease  directly.  When 
the  fragments  are  once  displaced  by  the  force  producing  the 
fracture,  the  muscles  exert  an  action  upon  them,  and  may 
oppose  reduction. 

Overlapping  is  one  of  the  most  important  and  constant  fea- 
tures in  fractures  of  both  bones  of  the  leg.  To  recount  all  of 
the  muscles  that  either  produce  or  maintain  the  retraction 
would  be  simply  enumerating  the  entire  list  that  make  up  the 
motive  power  of  the  leg.  The  line  of  action  is  towards  the 
knee,  the  broken  ends  of  the  lower  fragments  being  pulled 
upwards  past  the  fractured  surfaces  of  the  upper  fragments. 
The  weight  of  the  limb  causes  a  part  of  the  angular  and  rota- 
tory deformity,  and  the  winding  course  of  some  of  the  mus- 
cles the  rest  of  it.  The  direction  of  the  force  producing  the 
fracture  will  always  vary  the  line  of  the  displacement;  for, 
applied  from  the  outside  of  the  limb  it  will  be  disposed  to 
displace  the  portions  of  bone  inwards;  and  applied  from  the 
inside,  it  influences  them  in  the  opposite  direction. 

The  fibula,  in  fractures  of  both  bones  of  the  leg,  has  very 
little  influence  upon  displacement ;  the  fractured  ends  present 
so  small  a  surface  that  very  little  force  destroys  their  apposi- 
tion, and  if  the  bone  be  broken  into  more  than  two  pieces  the 
muscles  destroy  their  parallelism,  so  that  perfect  coaptation 
of  the  fragments  is  exceedingly  rare. 


OF  THE  LEG. 


225 


FIG.  92. 


In  fractures  very  high  up,  near  or  through  the  head  of  the 
tibia,  \vhero  1  lu-y  may  be  when  direct  force  inflicts  the  in- 
jury, the  displacement  is  slight,  unless  the  fracture  be  much 
comminuted;  for,  in  this  situation  the  structure  of  the  bone 
i<  c;incellons,  which  causes  it  to  break  with  a  more  irregular 
fracture,  giving  the  surfaces  a  rough,  uneven  shape,  by  which 
the  ends  of  the  bone  are  locked  within  one  another,  and  re- 
quire a  powerful  force  to  displace  them.  Fracture  through 
the  head  of  the  tibia,  or  tb rough  the  lower  extremity  of  it,  is 
liable  to  be  oblique  or  nearly  vertical  in  its  course,  a  circum- 
stance that  always  renders  it  doubtful  whether  the  knee  or 
ankle-joints  are  not  complicated  in  the  injury,  rendering  the 
nature  of  the  lesion  much  more  serious  than  a  fracture  of  the 
shaft  of  the  bone. 

Fracture  of  the  internal  inalleolus  and  of  the  fibula  a  few 
inches  above  the  joint,  accompanied  with  partial  or  complete 
dislocation  of  the  ankle,  is  an  injury  of  a 
complicated  nature,  and  is  essentially  the 
same  as  "  Pott's  fracture"  of  the  fibula, 
with  laceration  of  the  deltoid  ligament, 
and  displacement  of  the  tibia  from  the 
astragalus  to  a  certain  extent. 

Fractures  through  the   extremities  of 

o 

the  bones  of  the  leg  are  not  easily  diag- 
nosed, especially  if  the  patient  be  not  ex- 
amined until  swelling  has  rendered  the 
case  obscure.  These  accidents  are  always 
accompanied  with  more  ecchymosis  and 
swelling  than  fractures  at  a  distance  from 
the  joints,  owing  to  the  nature  of  the 
force  that  produces  the  injury,  and  to  the 
fact  that  the  articular  structures  are  more 
or  less  injured  at  the  same  time,  which 
causes  the  effusion  to  be  greater  than  it 
otherwise  would  be.  On  July  6th,  Dr. 

Fracture  of  the  tibia  and  fibu-  A.  P.  Freeman  and  myself  were  called 
^snorthosee10t:nes?xtremi-  to  treat  Mrs.  Taylor,  of  West  Covington, 
Ky.,  who  had  the  evening  before  broken 

her  left  leg  just  above  the  ankle.     There  was  considerable 

swelling   and  discoloration    twelve  hours  after  the  accident 

occurred. 
15 


The  sreneral  contour  of  the  leg  showed  that  afrac- 

o  t-3 


226  FRACTURES. 

ture  existed  near  the  ankle,  but  the  line  of  separation  in  both 
bones  conld  not  be  determined  without  careful  manipulation. 
Crepitus  decided  the  nature  of  the  injury,  though  it  could  not 
be  ascertained  at  first  whether  the  grating-  sound  (.-aim-  1'rom 
the  tibia  or  fibula,  or  both.  The  concavity  on  the  outside  o! 
the  leg  led  to  the  suspicion  that  the  fibula  was  broken,  and 
lateral  motion,  with  the  finger  on  the  suspected  point,  made 
the  existence  of  fracture  certain.  Antero-posterior  motion 
developed  crepitus  between  the  fragments  of  the  tibia  ;  and 
the  fingers  pressed  upon  the  bone  just  above  the  ankle  dis- 
covered the  line  of  separation.  It  was  easier  to  comprehend 
the  break  in  the  fibula  than  it  was  the  certainty  of  fracture 
and  the  line  of  separation  in  the  tibia.  The  deviation  from 
the  ordinary  shape  of  the  limb,  consisting  of  some  angular 
defect,  a  visible  twist  or  rotatory  deformity  in  the  lower  part 
of  the  leg,  made  it  apparent  that  both  bones  had  been  broken. 
The  line  of  separation  in  the  tibia  was  too  nearly  transverse. 
and  there  was  too  little  displacement  to  admit  of  overlapping, 
therefore  whatever  of  deformity  existed  was  overcome  by  ex- 
tension made  with  the  hands.  Common  thin  board  splints 
were  wrapped  with  muslin,  and  applied  to  each  side  of  the 
leg,  and  bound  in  place  with  encircling  tapes  and  a  roller, 
compresses  being  used  to  help  secure  the  normal  shape  of  the 
limb.  In  five  weeks  consolidation  was  complete,  and  no 
shortening  or  rotatory  deformity  remained.  Xo  extending 
force  was  used  after  the  reduction,  for  none  was  required. 
The  interlocking  of  the  fragments  of  the  tibia  would  not  ad- 
mit of  overlapping. 

In  fractures  of  both  bones  of  the  leg  near  the  knee,  the  line 
of  separation  can  be  discovered  between  the  fragments  of  the 
fibula,  but  the  course  of  the  fracture-line  in  the  tibia  is  often 
quite  difficult  to  make  out.  The  tibial  fragments  are  apt  to 
remain  interlocked,  owing  to  their  broad  surfaces,  and  to  the 
little  power  of  the  muscles  over  them.  Crepitus  may  some- 
times be  elicited,  but  it  may  not  be  easy  to  determine  whether 
it  is  between  the  fragments  of  the  tibia  or  fibula.  If  much 
displacement  happens  to  be  produced  by  the  force  which 
caused  the  fracture,  or  if  the  line  of  separation  be  oblique,  the 
nature  and  extent  of  the  injury  are  not  difficult  to  understand. 

Fractures  of  the  bones  of  t.hc  leg  remote  from  the  joints, 
are  attended  with  signs  quite  unmistakable.  Crepitus  is 


OF  THE  LEG.  227 

easily  produced,  owing  to  the  mobility  that  exists  between 
the  fractured  portions.  When  the  fracture  exists  in  the  tibia 
only,  the  same  facility  does  not  always  exist,  for  the  iibula 
then  serves  as  a  splint  to  a  certain  extent,  and  keeps  the  frac- 
tured ends  of  the  tibia  in  apposition. 

Oropitus,  for  various  reasons,  can  not  always  be  produced 
even  when  both  bones  are  broken  somewhere  near  their  mid- 
dle ;  but  the  angular  deformity  which  can  be  produced  by 
bending  the  leg  in  any  direction,  sufficiently  demonstrates  the 
nature  of  the  lesion. 

The  inner  and  fore  part  of  the  tibia  being  quite  superficial, 
a  fracture  of  the  shaft  of  the  bone  may  at  once  be  recognized 
by  passing  the  finger  along  the  anterior  spine  ;  for  any  irregu- 
larity along  this  surface  will  be  easily  discovered,  and  indicate 
the  position  of  the  fracture.  The  point  of  fracture  in  the 
fibula  is  not,  as  already  stated,  on  the  same  level  with  that  of 
the  tibia,  especially  when  the  fracture  is  caused  by  indirect 
force  ;  for  the  fibula  is  found  to  yield  at  a  point  somewhere 
above  the  place  the  tibia  breaks.  The  most  frequent  kind  of 
displacement  in  the  fibula  is  inward  toward  the  tibia,  causing 
a  depression  which  may  be  felt  when  the  finger  is  pressed 
along  the  outside  of  the  bone ;  and  the  ends  of  the  tibia  can 
not  be  displaced  to  any  great  extent  without  the  ends  of  the 
fibula  moving  with  them.  Overlapping  of  the  fragments  of 
the  tibia  can  not  take  place  without  the  same  amount  of  dis- 
placement occurs  in  the  fibula. 


TREATMENT  OF  FRACTURES  OF  BOTH  BONES  OF 

THE  LEG. 

As  already  indicated,  when  detailing  the  course  pursued  in 
the  treatment  of  Mrs.  Taylor's  leg,  extension  and  counter- 
extension  are  not  always  required  in  the  management  of  frac- 
tures of  both  bones  of  the  leg.  However,  if  there  be  shorten- 
ing, or  an  opportunity  to  overlap  on  the  part  of  the  frag- 
ments, as  theie  almost  always  is  when  the  fracture  is  through 
the  shafts  of  the  bones,  those  forces  must  be  steadily  and  per- 
sistently maintained  as  long  as  a  retentive  apparatus  is  neces- 
sary, otherwise  some  degree  of  deformity  will  be  inevitable. 
If  there  is  a  disposition  to  overlap,  as  there  necessarily  will  be 


228  FRACTURES. 

when  the  fracture  is  oblique,  the  difficulty  in  preventing  this 
deformity  is  exceedingly  great.  The  surgeon  may  effectually 
reduce  the  fragments  to  their  proper  places,  and  carefully 
apply  suitable  means  to  retain  them  there,  yet  the  tendency 
to  overlap  is  so  pressing  that  the  pieces  of  bone  will  slip  past 
each  other,  unless  watched  and  guarded  against  with  the 
utmost  patience  and  skill.  The  facility  with  which  the 
broken  surfaces  escape  from  one  another,  while  the  dressing 
is  being  applied,  has  been  observed  by  every  one  familiar  with 
such  injuries.  The  force  and  dexterity  required  to  effect  re- 
duction in  the  event  of  much  overlapping,  and  in  irritable 
patients  whose  muscles  fly  into  a  state  of  spasm  as  soon  as  the 
limb  is  touched,  are  far  from  trifling.  The  influence  of  chlo- 
roform is  sometimes  needed  to  accomplish  a  successful  reduc- 
tion. In  reducing  fractures  of  the  leg,  an  assistant  should  be 
placed  so  as  to  fix  the  knee  firmly,  while  the  foot  is  grasped, 
and  steady  and  well  directed  extension  is  made  downwards. 
care  being  taken  to  unlock  or  disengage  the  fragments  by  gen- 
tle rotatory  motion.  In  manipulations  of  a  broken  leg  it  should 
be  borne  in  mind  that  large  arteries,  veins  and  nerves,  pass 
along  near  the  rough  and  sharp  edges  of  the  fragments,  and 
may  be  seriously  injured  by  careless  handling  of  the  limb. 

It  is  the  custom  of  some  surgeons  to  allow  a  broken  leg  to 
remain  several  days  under  the  influence  of  cooling  and  ano- 
dyne lotions,  before  an  attempt  is  made  at  reduction.  This 
course  might  do  in  a  hospital  where  the  patient  has  no  choice 
of  surgical  attendants,  but  in  private  practice  the  most  eminent 
practitioner  is  not  sure  of  holding  his  case  if  he  follow  such  a 
course.  Policy,  then,  is  against  the  practice,  even  if  it  have 
some  points  in  its  favor;  but  according  to  my  experience 
there  is  no  better  time  to  a'djust  a  fractured  bone  than  as  soon 
as  it  can  be  done  conveniently.  The  muscles  do  not  readily 
relax  after  they  have  been  allowed  to  contract  for  several 
days ;  besides,  the  patient  does  not  rest  well  with  the  limb  in 
a  broken  and  unsupported  state.  There  is  a  teeling  of  insecu- 
rity in  an  undressed  fracture  that  is  absolutely  tormenting  ; 
every  motion  of  the  body  imparts  pain  and  invites  a  spasmodic 
action  of  muscles  in  the  vicinity  of  the  fracture.  If  it  be  im- 
possible to  reduce  a  compound  fracture  on  account  of  the  mus- 
cular contraction  and  spasm,  the  influence  of  an  anaesthetic 
will  put  the  patient  into  such  a  state  of  relaxation  that  the 


Or  THE  LEG. 


229 


FIG.  93. 


\v<>i*st  case  can  be  managed  successfully.  If  the  wound  in  the 
integument  be  too  small  for  the  protruding  fragment  to  return, 
it  may  be  enlarged  slightly  to  take  off  the  tension.  The  ne- 
cessity for  sawing  oft'  a  piece  of  the  bone  in  order  to  accom- 
plish easy  and  speedy  reduction,  can  rarely  or  never  exist. 
However,  it  would  be  necessary  to  resect  a  point  of  the  bone 
if  it  could  not  be  returned  to  its  proper  position,  yet  such  a 
procedure  is  to  be  avoided  if  possible.  I  can  not  endorse  the 
following  from  Prof.  Hamilton  :  "  Resecting  thus  the  end  of 
an  oblique  fragment  does  not  generally  affect  in  any  degree 
the  length  of  the  limb,  or  interfere  with  a  prompt  and  perfect 
cure,  but  on  the  contrary  it  often  is  advan- 
tageous in  every  point  of  view.'"' 

The  application  of  extending  force  in 
those  instances  where  the  overlapping  de- 
mands it,  taxes  the  ingenuity  of  those  unac- 
customed to  make  a  "'  hitch"  upon  the  foot. 
Inn-ton's  handkerchief,  as  it  is  sometimes 
called,  may  be  employed  as  a  means  of 
making  extension.  It  can  be  applied  as  fol- 
lows: a  handkerchief  of  good  size  being 
folded  into  a  cravat,  is  so  laid  against  the 
point  of  the  heel  that  one-third  of  the  hand- 
kerchief shall  be  on  one  side  and  two-thirds 
on  the  other ;  after  which  the  longest  end 
is  to  be  carried  round  across  the  instep  to 
the  opposite  side,  where  it  takes  a  turn 
around  the  other  extremity  of  the  handker- 
chief, and  is  then  carried  under  the  sole  of 
the  foot  to  the  other  side  of  the  ankle,  where 
it  takes  a  fold  around  the  first  turn.  The 
two  free  ends  reaching  below  the  foot  are 
to  be  used  for  making  extension  with  what- 
ever apparatus  the  surgeon  chooses  to  em- 
ploy. A  gaiter  has  been  one  of  the  means 

°f  I1'^illg  ^  to  theailkle,  when  exten,iou 

^  11Cc,(ied  ;  bur  if  the  fracture  be  near  the 
ankle-joint,  the  folded  handkerchief  is  not  endurable  without 
great  suffering  and  excoriation.  The  heel  and  structures 
about  the  ankle  are  proverbially  intolerant  of  pressure,  and 
the  accident  renders  them  more  so. 


Hitch  made  upon  the 
ankle  and  foot  with  a 
handkerchief  folded 
like  a  era  vat. 

FIG.  94. 


A  gaiter-like  appliance  to 


230 


Fr>ACTn;i-:s. 


FIG.  95. 


The  adhesive  strip  fastening  is  the  least  objectionable  of  all 
kindred  contrivances  for  making  extension.  Tin-  foot  and 
ankle  are  to  be  covered  in  with  narrow  strips 
of  adhesive  plaster,  then  the  vertical  side 
strips  of  greater  width  are  made  to  adhere 
partly  to  the  skin  and  in  part  to  the  envelop- 
ing material,  and,  finally,  over  both  a  few  en- 
circling strips  are  applied,  which  complete 
the  first  stage  of  the  dressing.  The  surgeon 
can  take  his  choice  of  these  three  forms  of 
making  fast  to  the  foot  and  ankle,  but  I  much 
prefer  the  "  hitch  "  by  adhesive  strips. 

If  the  fracture  be  higher  up,  long  pieces  of 
adhesive  plaster  may  be  used  and  a  firmer 
hold  secured.  A  roller  may  be  used  to 
envelope  the  leg  after  the  strips  arc  applied 
if  its  compressing  influence  seems  to  be  in 
sary,  though  I  am  not  in  favor  of  a  bandage 
next  the  skin  which  may  exert  a  constricting 
influence. 

The  next  step  in   the  dressing  consists  in 
°f  making  applying  the  retentive  apparatus,  which  may 


Adhesive  strip  fasten 
ing  made  to  the  foot 
and  ankle,  for  the 


FIG.  96. 


I'rcgsing  for  the  leg,  nftfir  both  honos 
are  broken,  in  progress  of  applica- 
tion. 


con>ist  of  two  wooden  side  splints, 
well  wrapped  ;  and  over  these  the 
ends  of  a  many  tailed  bandage  may 
be  lapped  to  hold  them  securely  in 
place.  Figure  !M;  shows  the  dress- 
ing in  this  second  stage,  with  a  few 
of  the  lower  strips  lapped  across. 
Two  or  three  encircling  ties  may  be 
used  to  retain  the  splints  in  place 
until  the  full  retentive  influence  of 
the  many  tailed  bandage  is  brought 
to  bear.  A  roller  may  be  used  in- 
stead of  the  bandage1  of  strips.  I 
prefer  the  roller  in  ordinary  simple 
fractures;  and  the  bandage  of 
strips  in  compound  injuries,  for  the 
latter  is  the  easiest,  to  be  opened 
and  closed  when  the  wound  is  ex- 
amined. 


OF  THE  LEG. 


231 


The  next  step  in  the  Crossing  is  to  give  the  leg  the  position 
it  is  going  to  occupy,  and  to  apply  the  extending  and  counter- 
extending  forces.  The  double  inclined  plane  apparatus  is 
used  by  some  surgeons  to  give  the  limb  the  flexed  position 
and  to  secure  not  only  what  force  there  is  to  be  obtained  by 
this  attitude,  but  to  apply  by  means  of  ties  and  screws  as 
much  in  addition  as  may  be  demanded.  Other  surgeons  pre- 
fer the  straight  position  of  the  limb,  using  a  fracture  box,  as 
•it  is  called,  or  a  contrivance  made  of  boards  to  reach  along 
the  sides  of  the  leg,  a  bottom  piece,  a  foot  piece  which  is 
nailed  to  the  bottom  and  side  pieces,  and  a  movable  foot  piece 
to  which  the  gaiter,  handkerchief,  or  the  side  strips  of  the  ad- 
hesive application,  are  tied.  If  the  double  inclined  plane  be 
used,  counter-extension  maybe  left  to  the  weight  of  the  thigh 
and  body,  and  extension  made  by  lashing  the  foot  to  the  mov- 
able foot-piece  of  the  apparatus,  and  then  drawing  it  steadily 
downwards  by  turning  the  screws,  or  by  other  means  em- 
ployed to  accomplish  the  same  object.  To  describe  all  the  in- 
ventions and  improvements  of  this  kind  introduced  to  the 
notice  of  the  profession,  would  require  more  space  than  can 
be  granted  in  a  work  of  this  kind.  The  accompanying  cut 
represents  an  apparatus  for  making  extension  and  counter- 
extension  below  the  knee.  The  foot  is  fastened  to  the  mov- 
able foot-piece  by  means  of  a  gaiter ;  and  the  counter-extend- 

FIG.  97 


1,  Side  of  fracture  box ;  2,  bottom  of  fracture  box  ;  3,  movable  foot-piece ;  4,  wooden  screws 

to  adjust  foot-piece ;  5,  gaiter  ;  G,  bolt  of  leather  encircling  the  leg  below  the  knee, 

for  counter-extending  force  ;  7,  hooped  rod  to  sustain  the  force. 


ing  force  is  obtained  by  moans  of  a  piece  of  sole  leather  which 
is  laced  together  after  encircling  the  leg  just  below  the  knee. 
Some  tapes  extend  from  holes  or  loops  in  the  upper  edge  of 
the  leather  band,  to  an  iron  rod,  which  is  hooped,  and  has  its 
t\vo  ends  secured  to  the  upper  extremity  of  the  box, — the 
hoop  is  made  adjustable  by  means  of  a  couple  ol'  wire  loops 
driven  into  the  upper  ends  of  the  sides  of  the  box.  The  same 


232 


FRACTURES. 


FIG.  98. 


principle  is  applied  to  every  apparatus  of  the  kind,  though 
many  of  these  contrivances  vary  in  general  characteristics. 

It  is  not  necessary  to  employ  a  complicated  apparatus  to 
treat  successfully  fractures  of  both  bones  of  the  leg.  The  ex- 
tending strips  of  adhesive  plaster  maybe  attached  to  the  foot 
of  the  bed,  and  then  counter  extension  can  be  produced  by 
elevating  the  foot  posts  of  the  bedstead,  as  already  recom- 
mended in  the  treatment  of  fractures  of  the  thigh.  If  this 
method  be  adopted  a  sand  bag  should  be  placed  under  the 
knee,  and  other  bags  may  be  laid  against  the  outside  of  the 
limb  to  thwart  the  tendency  to  eversion.  In  some  instances 
the  leg  should  be  supported  between  two  junk  bags  in  order 
to  take  the  weight  of  the  limb  from  the  heel  which  is  liable 
to  slough  under  prolonged  though  moderate  pressure.  If  the 
ends  of  the  splints  press  heavily  at  their  upper  or  lower  ex- 
tremities, so  as  to  threaten  ulceration,  cushions  of  cotton, 
nair,  or  wool  should  be  placed  under  them.  The  limb  must 
be  watched  very  narrowly,  to  prevent  any 
morbid  action  from  doing  serious  mischief. 
Vesication  is  a  common  condition  after 
fractures  of  the  leg;  and  the  bladders  of 
serum  that  form  .beneath  the  dressings,  out 
of  sight,  may  break  and  degenerate  into 
ulcers  and  ugly  sloughs.  If  the  vesicles  are 
very  large  and  tense,  they  may  be  pricked 
to  allow  the  serum  to  escape.  These  blis- 
ters commonly  dry  up  in  the  course  of  a 
week  or  two,  and  leave  no  bad  effects. 

In  a  fracture  of  both  bones  of  the  leg,  es- 
pecially if  the  tibia  be  broken  at  one  point, 
and  the  fibula  at  another,  the  tendency  to 
overlap  on  the  part  of  the  fragments  is  con- 
siderable, therefore  careful  and  persevering 
efforts  must  be  made  to  obviate  shortening. 
The  accompanying  diagram  represents  with 

Consolidation  of  the  frag-  SCl'UpuloUS    CXaCtllCSS    the    bones  of    tllC    I'1-' 

5rthtbo^rofhtheUTeS,f  as  found  after  having  been  under  ibe  treat. 

showing  deformity.  '  ment  of  :l  s,,,.geon  of  moro  than  ordinary 
skill  and  experience.  The  patient  died  of  visceral  disease  in 
five  months  after  receiving  the  fracture.  The  limb  was  three 
quarters  of  an  inch  too  short,  as  may  be  judged  by  the 


OF  THE  LEG.  233 

overlapping  of  the  fragments,  and  there  was  angular  defor- 
mity, besides  some  arising  from  rotation.  The  upper  fragment 
of  the  fibula  split,  and  the  wedge  shaped  broken  edge  of  the 
lower  fragment  was  forced  between  the  splinters.  The  injury 
occurred  from  indirect  violence,  the  patient  in  a  fall  striking 
upon  one  foot.  The  consolidation  between  the  fragments  was 
found  to  be  complete,  but  the  rough  points  of  the  badly  op- 
posed .fragments  were  little  affected  by  the  polishing  process 
which  at  length  makes  such  irregularities  comparatively 
smooth. 

Measurements  during  treatment  should  be  frequently  made 
to  determine  whether  shortening  is  taking  place.  With  the 
body  straight,  and  the  legs  parallel,  a  tolerably  correct  com- 
parison can  be  made  between  the  lengths  of  the  two  limbs. 
However,  it  is  more  satisfactory  to  measure  from  the  umbilicus 
or  symphysis  pubis  to  the  inner  malleolus  of  each  ankle.  If 
the  patient  be  a  woman  the  measurement  may  be  made  from 
the  patellae  to  the  malleoli. 

When  the  two  limbs  are  side  by  side,  any  deviation  of  the 
broken  leg,  as  by  rotation,  is  quickly  detected.  As  a  sight  is 
taken  up  the  limb  to  the  body  the  great  toe  should  be  on  a 
line  that  strikes  the  inner  edge  of  the  patella. 

The  foot  must  be  watched  to  see  that  the  heel  be  not  drawn 
upwards  too  much  by  the  contracted  condition  of  the  sural 
muscles  acting  through  the  tendo-Achillis.  When  the  obli- 
quity of  the  fracture  favors  that  kind  of  contraction,  as  well 
as  a  slipping  backwards  of  the  foot  and  whatever  of  leg  is 
below  the  break  in  the  bone,  the  inclination  or  tendency  must 
be  arrested  by  the  dressings  and  the  proper  use  of  sand  bags. 
If  a  cushion  or  junk  bag  be  carelessly  placed  just  above  the 
fracture  the  weight  of  the  leg  would  tend  to  displace  the  foot 
backwards. 

In  cases  admitting  of  the  leg  resting  upon  its  side,  that 
position  is  favorable  to  ease  and  apposition.  Some  surgeons 
prefer  to  dress  the  leg  with  the  view  of  having  the  limb  gently 
flexed  and  laid  upon  its  side.  After  fracture  of  one  of  the 
bones  of  the  leg  the  limb  may  be  placed  in  any  attitude,  for 
no  extending  apparatus  interferes  with  free  movements  ;  but 
when  both  bones  are  broken,  and  theie  be  danger  of  overlap- 
ping, the  limb  can  not  be  freed  from  the  machine  or  apparatus 
that  has  to  be  employed  to  secure  extension. 


234 

In  some  instances  it  may  do  to  lay  aside  the  ordinary  appli- 
ances, and  to  adopt  the  stiff  dressing  in  their  stead.  The 
common  starch  dressing,  when  once  dry,  will  obviate  the  ten- 
dency to  shorten.  However,  the  limb  may  shrink  after  it  has 
been  in  the  immovable  dressing  for  a  few  days,  affording  op- 
portunity for  lateral  displacement  and  shortening.  I  never 
feel  satisfied  with  a  starch  dressing  when  both  bones  are 
broken.  In  exceptional  cases,  where  it  becomes  necessary  for 
the  patient  to  be  moved  by  carriages  and  railroads  before  con- 
solidation of  the  broken  bones  has  taken  place,  the  immov- 
able or  stiff  dressing  should  most  certainly  be  employed. 

Debilitated,  dropsical,  and  broken  down  constitutions  are 
exceedingly  unfavorable  to  rapid  bony  union;  and  in  an  occa- 
sional instance  no  consolidation  will  take  place.  In  18iii!  a 
raftsman  on  the  rivpr  got  his  leg  caught  in  some  lumber  and 
broke  both  bones  in  the  lower  third  of  the  limb,  lie  was 
taken  to  the  house  of  Mr.  Harrison,  of  Newport,  Ky.  1  ac- 
cepted an  invitation  to  take  charge  of  the  case,  and  treated  it 
in  the  ordinary  way.  In  the  course  of  ten  days  the  limb  took 
on  a  flabby,  dropsical  appearance,  and  presented  evidences  of 
defective  vitality.  At  the  end  of  four  weeks  from  the  acci- 
dent, I  perceived  crepitus  between  the  fragments,  and  the  limb 
exhibited  almost  as  much  mobility  at  the  seat  of  fracture  as 
at  first.  The  limb  was  redressed,  and  the  patient  who  Avas 
seriously  impaired  in  health  from  the  excessive  use  of  liquor 
and  exposure,  was  put  upon  a  stimulating  and  nourishing 
diet,  and  three  glasses  of  ale  a  day  were  allowed  him.  He 
soon  began  to  improve  in  general  appearance,  and  the  ley 
which  was  redressed  once  a  week,  showed  more  firmness  and 
vitality.  At  the  end  of  the  eighth  week  the  limb  bad  stiffened 
at  the  point  of  fracture,  very  little  deformity  existing.  I  no\v 
put  the  leg  in  a  starch  dressing,  and  had  the  patient  begin  to 
take  exercise  on  crutches.  In  four  months  from  the  reception 
of  the  injury,  the  patient  walked  to  my  office,  using  a  cane  to 
steady  himself.  There  was  no  perceptible  shortening,  though 
the  upper  fragment  of  the  tibia  projected  so  it  could  be 
plainly  felt.  The  consolidation  seemed  as  perfect  as  in  any 
case.  During  the  early  part  of  the  treatment  1  was  afraid  of 
false  joint,  but  the  sequel  showed  that  the  case  was  to  be 
looked  upon  as  representing  delayed  or  tardy  reparative 
action. 


OF  THE  TIBIA.  235 


FRACTURE    OF    THE    TIBIA    SINGLY. 

As  has  been  previously  stated,  a  force  which  breaks  the 
tibia  is  generally  sufficient  to  snap  the  fibula  also.  However, 
the  tibia  is  sometimes  broken  singly,  the  fibula  remaining  in- 
tact. Direct  violence,  such  as  the  kick  of  a  horse,  or  a  blow 
from  some  hard  body,  may  be  the  cause.  James  Bucking- 
ham, in  January,  1864,  slipped  while  stepping  from  the  street 
to  the  sidewalk  at  the  corner  of  Sixth  and  Elm  Streets,  and 
hit  his  leg  live  or  six  inches  below  the  knee  against  the  sharp 
corner  of  the  curb-stone.  He  distinctly  heard  something- 
snap,  and  immediately  experienced  great  pain  in  the  limb. 
He  was  near  home  and  attempted  to  walk  the  distance,  but 
the  distress  occasioned  by  an  effort  to  use  the  leg  compelled 
him  to  sit  down.  It  was  before  daylight  in  the  morning,  and 
as  nobody  passed  along  to  help  him,  he  dragged  himself  home 
the  distance  of  a  square,  on  his  hands  and  sound  hip  and  leg. 
In  an  hour  or  so  after  the  accident  I  found  the  tibia  broken  a 
few  inches  below  the  knee,  and  the  fibula  as  sound  as  ever. 
The  upper  fragment  projected  a  little,  but  there  was  no  per- 
ceptible rotation  of  the  leg  below,  or  other  deformity. 

In  1867,  Fritz  Gorman,  a  lad  of  eight  years,  was  hit  by  a 
runaway  horse,  on  Front  Street,  and  received  an  injury  of  the 
leg.  I  was  called  to  the  case,  and  found  a  fracture  of  the  tibia 
three  inches  above  the  ankle,  with  the  anterior  sharp  edge  of 
the  upper  fragment  protruding  through  the  skin.  The  fibula 
had  escaped  fracture.  These  cases  are  mentioned,  not  as  pos- 
sessing any  special  interest ;  but  to  show  what  kind  of  forces 
may  break  the  tibia  alone.  In  the  first  case  the  patient  said 
"  the  weather  was  so  cold  there  must  have  been  frost  in  his  leg." 
There  is  a  popular  notion  that  the  bones  are  more  fragile  when 
the  weather  is  intensely  cold.  Probably  this  is  an  error 
founded  on  the  fact  that  more  fractures  occur  in  frosty  weather 
than  at  other  seasons,  the  sufferers  ascribing  their  misfortunes 
to  osseous  fragility  and  not  to  the  slippery  condition  of  every- 
thing frosted,  where  the  real  cause  should  be  placed.  It  is 
possible  that  the  highly  contractile  state  of  the  muscles  may, 
in  cold  weather,  increase  the  frequency  of  broken  limbs  ;  and 
if  it  be  a  fact  that  intoxicated  persons  whose  muscular  system 
is  in  a  loose,  flaccid  condition,  can  receive  heavy  falls  and 


286  FRACTURES. 

• 

enjoy  an  immunity  from  fractures,  it  becomes  highly  probable 
that  a  tense  state  of  the  soft  tissues  favors  fracture. 

In  fracture  of  the  tibia  the  line  of  separation  may  be  trans- 
verse, oblique,  or  irregular  in  its  course.  Being  the  result  of 
direct  violence  in  a  majority  of  instances,  the  transverse  vari- 
ety prevails,  especially  if  the  fracture  be  near  the  extremities 
of  the  bone.  I  was  once  called  by  Dr.  Win.  Sherwood,  of 
this  cit}',  to  see  a  case  in  his  practice,  in  which  the  fracture 
extended  transversely  through  the  tibia  within  two  inches  of 
the  knee-joint, — the  fibula  was  not  fractured.  There  was 
little  or  no  displacement,  and  consolidation  took  place  in  five 
or  six  weeks.  Direct  violence  was  the  cause  of  the  injury. 
Dr.  Van  Ingen,  for  a  while  in  this  city,  exhibited  to  me  a 
drawing  which  he  had  made  to  represent  an  oblique  fracture 
through  the  upper  part  of  the  tibia,  the  line  of  separation  ex- 
tending into  the  knee-joint.  He  says  the  case  was  treated  by 
him  successfully  near  Schenectadv,  X.  Y.  His  diagram  aU> 
showed  a  fracture  of  the  inner  c-ondyle  :>f  the  femur,  which 
was  a  part  of  the  same  accident.  It  is  possible  he  may  have 
been  mistaken  in  regard  to  the  extent  of  the  injury. 

I  once  took  professional  charge  of  a  teamster  who,  in  jump- 
ing from  his  wagon  to  the  ground,  received  a  longitudinal 
fracture  of  the  lower  extremity  of  the  tibia.  The  line  of 
separation  began  in  the  articular  surface  of  the  lower  end  of 
the  bone,  and  terminated  two  inches  above  the  joint,  disen- 
gaging a  wedge-shaped  splinter  of  bone,  including  the  inter- 
nal malleolus.  The  piece  united  without  displacement  or  de- 
formity, but  the  function  of  the  joint  was  restricted  by  partial 
anchylosis,  lasting  a  year  or  more.  The  patient  ultimately 
recovered  the  full  use  of  the  limb.  In  fractures  of  the  tihia 
through  the  lower  third  of  the  bone,  the  foot,  including  the 
leg  below  the  fracture,  is  liable  to  exhibit  a  twist,  indicating 
more  distortion  than  might  be  expected  after  a  fracture  of 
only  one  bone  of  the  leg.  The  twist  in  the  limb  is  permitted 
by  the  length  and  slender  state  of  the  fibula,  and  its  lateral 
mode  of  articulation. 

The  symptoms  of  fracture  of  the  tibia  alone,  are  quite  dis- 
tinct and  easy  of  recognition,  if  the  solution  of  continuity  he 
anywhere  near  the  centre  of  the  bone,  for  the  inequality  at 
the  line  of  separation  will  be  felt  when  the  finger  is  pressed 
along  the  spine  of  the  bone;  but  if  the  break  be  near  either 


OF  THE  TIBIA. 


FIG.  99. 


Fracture  of  the  tihia;  the  fibula 
remaining  unbroken. 


extremity,  and  the  direction  of  the  fracture  line  be  transverse, 
without  appreciable  displacement,  the  diagnostic  powers  of 
the  surgeon  may  be  put  severely  to  the  test.  The  perfect  con- 

tact  of  the  fragments  often  prevents 
crepitation,  and  the  existence  of  the 
fracture  has  to  be  inferred  from  the 
nature  of  the  force  applied,  the 
sharp,  circumscribed  and  persistent 
pain  increased  by  pressure  or  an  at- 
tempt to  walk,  and  the  local  en- 
gorgement. If  mobility  and  crepi- 
tus  can  be  detected  when  the  frag- 
ments are  pressed  in  opposite  direc- 
tions the  diagnosis  of  fracture  is 
made  out,  but  not  of  the  tibia  alone ; 
for,  the  diagnosis  is  not  complete 
until  it  is  decided  that  the  lesion  is 
limited  to  the  tibia,  and  that  the 
fibula  remains  unbroken.  When  it 
is  known  that  a  fracture  of  the  leg 
exists  it  is  safe  to  consider  both 
bones  broken,  until  it  is  positively  determined  that  the  fibula 
is  intact.  The  crepitus  elicited  may  come  from  a  fracture  of 
one  bone  or  both.  To  determine  whether  the  fibula  be  broken 
the  bone  must  be  tested  its  entire  length.  The  finger  is  to  be 
pressed  along  its  course  slowly  while  the  limb  is  carried  back- 
wards and  forwards  and  laterally  to  develop  a  point  in  which 
there  is  mobility  or  inequality. 

TREATMENT  OF  FRACTURES  OF  THE  TIBIA.  —  Tn  most  in- 
stances a  fracture  of  the  tibia  alone  can  be  managed  with 
ease  and  success.  The  coaptation  of  the  fragments  when 
there  is  displacement,  is  generally  not  a  difficult  matter. 
If  the  projection  of  the  upper  fragment  forward  be  consider- 
able, it  may  require  some  tact  to  get  it  back  into  place.  The 
influence  of  an  anaesthetic  maybe  employed  to  overcome  mus- 
cular rigidity.  The  tendo-Achillis  has  been  divided  to  over- 
come the  spasm  and  contraction  of  the  gastrocnemius  and 
soleus,  but  such  a  course  is  rarely  if  ever  necessary.  I  have 
never  seen  a  case  that  demanded  a  section  of  the  tendon  to 
assist  in  reduction. 


FRACTURES. 

The  twist  or  rotation  which  follows  a  fracture  near  the  ankle 
is  worse  to  overcome  than  the  angular  deformity  following 
fractures  of  the  tibia  higher  up. 

In  an  ordinary  case  the  limb  from  the  toes  to  the  knee  may 
be  enveloped,  not  tightly,  in  a  common  muslin  roller  to  mod- 
ify swelling,  congestion,  and  muscular  action  ; 
two  lath  splints  long  enough  to  reach  from 
the  knee  to  the  ankle  may  be  laid  on  the 
sides  of  the  leg,  and  bound  there  by  another 
roller.  If  there  be  much  tendency  to  the  for- 
ward projection  of  either  fragment  a  third 
splint  may  be  laid  upon  the  posterior  aspect 
of  the  leg,  and  a  compress  upon  the  anterior 
surface  of  the  limb  near  the  fracture,  and  so 
placed  as  to  bear  upon  the  projecting  piece  of 
bone,  though  not  at  its  very  point.  Side 
splints  have  been  prepared  with  concavities  to 
tit  the  form  of  the  leg,  and  with  holes  near 
their  lower  ends  to  avoid  pressure  upon  the 

splints  being  bound  malleoli.  These  carved  and  nicelv  construct- 
to  the  Ie<*  after  frac- 
ture of  the  tibia.  ed  splints  are  applied  with  ease,  and  they  an- 
swer an  excellent  purpose  in  most  instances.  Almost  every 
surgeon  has  on  hand  more  or  less  of  such  appliances  for  treat- 
ing fractures.  He  also  keeps  ready  prepared  a  supply  of  rol- 
lers, raw  cotton,  adhesive  plaster,  and  other  material  for 
emergencies.  Some  houses  have  so  few  comforts  and  imple- 
ments, that  the  surgeon  is  greatly  troubled  to  find  material 
from  which  to  construct  splints  and  bandages.  And  on  re- 
markable occasions,  when  from  a  railroad  accident,  or  from 
the  fall  of  a  building,  a  dozen  fractures  may  need  attention  at 
once,  ample  preparation  for  the  extraordinary  occasion  re- 
dounds to  the  credit  and  advantage  of  the  surgical  attendants. 
However,  if  a  practitioner  of  medicine  and  surgery  be  called 
to  treat  a  fracture,  and  he  be  not  prepared  with  the  usual  ap- 
pliances, he  should  be  competent  to  construct  extemporane- 
ously such  splints  and  bandages  as  the  necessities  of  the  case 
demand.  Sheets  may  be  torn  into  strips,  sewed  together,  and 
wound  into  rollers  ;  splints  can  be  whittled  from  lath  or  shin- 
gles, cigar  boxes,  and  thin  boards;  pillows  do  for  cushions  and 
supports  until  bags  of  dry  sand  can  be  obtained. 


OF  THE  TIBIA.  239 

After  a  fracture  of  the  tibia  1ms  been  dressed,  the  limb  may 
be  laid  in  a  position  favorable  to  ease  and  repose.  The 
patient  need  not  be  confined  to  bed,  but  may  lie  upon  a  sofa 
or  lounge.  The  limb  may  be  flexed,  extended,  or  laid  oil  its 
side,  just  as  the  patient  chooses.  The  fibula  prevents  short- 
ening, and  the  splints,  bandages,  compresses,  and  other  parts 
of  the  dressing  obviate  mobility,  rotation,  and  angular  defor- 
mity. Lotions  shrink  the  bandages,  and  favor  vesi cation  of 
the  skin,  therefore  it  is  generally  better  to  allow  the  dressings 
to  continue  dry.  An  opiate  may  be  needed  to  subdue  pain 
during  the  first  few  days.  The  bowels  should  be  moved  every 
two  or  three  days,  and  the  diet,  after  the  first  week,  ought  to 
be  quite  nourishing. 

The  immovable  dressing,  of  starch,  or  plaster  of  Paris,  is 
suitable  for  treating  fractures  of  the  tibia.  It  may  be  well  to 
keep  the  limb  in  an  ordinary  dressing  for  a  week  or  ten  days, 
or  until  the  swelling  subsides,  and  then  it  saves  trouble  to  en- 
case the  leg  in  a  stiff  dressing,  and  let  the  patient  go  about  on 
crutches.  Even  with,  the  ordinary  dressing  the  patient  can 
get  about  on  crutches  without  pain,  or  danger  of  mobility  at 
the  seat  of  fracture.  However,  no  weight  should  be  borne  on 
the  limb  for  five  or  six  weeks  after  the  accident.  Consolida- 
tion to  the  extent  of  preventing  mobility  may  take  place  in 
four  weeks,  but  the  callus  is  not  sufficiently  hard  in  all  its 
parts  to  obviate  deformity  under  great  pressure.  There  can 
be  no  harm  in  keeping  light  splints  and  a  bandage  applied  to 
the  leg  for  a  week  or  two  after  the  ordinary  time  for  undress- 
ing a  limb  has  passed. 

After  fracture  of  the  tibia  extending  into  the  knee-joint,  the 
danger  is  anchylosis,  therefore  the  limb  should  be  slightly 
flexed,  and  placed  on  a  pillow  or  between  two  sand  bags  so 
arranged  as  to  support  the  knee  and  produce  some  lateral 
pressure.  Lotions  may  be  used  for  two  weeks,  then  paste- 
board, leather,  gutta  percha,  or  other  pliable  splints.  In  four 
or  five  weeks  from  the  accident,  passive  motion  ought  to  be 
begun  and  kept  up  for  months,  or  until  the  joint  recovers  its 
functions. 

In  a  longitudinal  fracture  of  the  lower  end  of  the  tibia,  in- 
cluding the  inner  malleolus  with  the  detached  fragment,  the 
foot  and  leg  should  be  bandaged,  and  great  vigilance  exer- 
cised to  prevent  any  lateral  distortion  at  the  ankle.  If  the 


240  FRACTURES. 

foot  incline  too  much  outward  or  inward,  the  tendency  may- 
be overcome  with  a  properly  applied  splint,  compresses,  band- 
ages and  sand  bags. 

FRACTURES    OF    THE    FIBULA. 

The  fibula  being  a  slender  bone,  may  be  broken  at  any 
point,  especially  by  direct  violence.  A  smart  blow  upon  the 
outside  of  the  leg  has  been  known  to  snap  the  fibula  into  frag- 
ments. But  the  most  common  cause  of  fracture  in  this  bone 
is  a  sudden  and  violent  twist  of  the  foot  outwards,  which 
dislocates  the  ankle  and  breaks  the  fibula  a  few  inches  above 
the  outer  malleolus.  The  accident  often  arises  from  getting 
the  foot  caught  in  a  hole  or  cleft  while  walking.  Sir  Astley 
Cooper  fractured  his  right  fibula  by  falling,  after  his  foot  was 
entangled  between  two  pieces  of  ice.  Booth,  in  his  leap  to 
the  stage  of  the  theatre,  after  shooting  President  Lincoln,  had 
his  foot  powerfully  deflected  by  having  the  spur  .on  his  boot 
catch  in  a  displayed  flag,  and  thereby  sustained  a  fracture  of 
the  fibula. 

The  frequency  of  fracture  of  the  fibula  and  dislocation  of 
the  ankle  from  forcible  abduction  of  the  foot,  is  notable. 
Every  experienced  surgeon,  when  called  to  an  injury  of  the 
leg  at  a  point  near  the  foot,  at  once  examines  the  fibula  just 
above  the  external  malleolus,  as  if  he  expected  to  find  the 
bone  broken  at  that  point.  In  fact  the  lesion  is  too  common 
to  escape  the  observation  of  any  practitioner  of  moderate  ex- 
perience. 

The  oflice  of  the  fibula  is  not  to  take  part  in  supporting  the 
weight  of  the  body,  but  to  strengthen  and  complete  the 
mechanism  of  the  ankle-joint  upon  its  outside.  The  bone 
also  serves  to  give  attachments  to  a  large  number  of  muscles, 
and  lends  support  to  the  tibia. 

A  kick,  or  smart  blow  of  any  kind,  is  enough  to  produce  a 
fracture  of  the  shaft  anywhere  between  its  two  extremities. 
I  have  treated  fracture  of  the  fibula  through  the  upper  third 
of  the  bone  which  was  caused  by  the  rapid  passage  of  an  or- 
dinary buggy  wheel ;  and  in  another  instance  the  kick  of  a 
steer  was  the  cause.  In  both  instances  the  men  were  able  to 
walk  after  the  injuries  were  received,  though  great  pain  at- 
tended the  taking  of  each  step.  Considerable  tumefaction 


OF  TIIE  FIBULA. 


241 


occurred  atthe  seat  of  fracture ;  aud,  the  upper  fragment  being 
driven  inwards  in  both  cases,  I  was  able  to  detect  the  dis- 
placement by  pressing-  the  fingers  along  the  course  of  the 
bone.  The  projecting  end  of  the  lower  fragment  stood  out 
distinctly,  and  could  be  seen  as  a  salient  point,  as  well  as  felt. 
No  particular  mobility  Avas  discovered,  but  the  foot  could  be 
FIG.  101.  rotated  to  a  greater  extent,  or  through  a  larger 
arc,  than  in  the  sound  leg.  Distinct  crepitation 
was  not  elicited,  for  the  broken  surfaces  could 
not  be  brought  in  apposition,  though  manipu- 
lation of  the  limb  forced  them  in  contact. 
The  dressing  in  each  case  consisted  of  two 
padded  side  splints  and  a  bandage.  Both 
cases  recovered  without  apparent  deformity, 
or  defect  in  the  functions  of  the  limbs. 

The  specimen  represented  in  the  accompany- 
ing diagram  shows  a  double  fracture  of  the 
libnla  above  the  middle  of  the  bone,  and  the 
central  fragment  deflected,  probably  by  mus- 
cular action,  from  its  normal  course.  The  ap- 
position is  far  from  perfect,  yet  the  reparative 
action  formed  an  osseous  connection  between 
the  fragments.  The  tibia  shows  no  sign  of 
ever  having  been  broken.  The  double  frac- 
ture may  have  been  produced  by  the  same 
kind  of  violence  that  would  cause  a  single  frac- 
ture. There  was  a  slight  deformity  apparent  in 
that  part  of  the  limb  before  a  full  dissection  revealed  the  true 
state  of  the  parts.  The  history  of  the  case  is  not  known.  I 
have  another  specimen  of  the  bones  of  the  leg  in  which  the 
tibia  shows  the  marks  of  an  old  fracture  three  inches  above  its 
lower  extremity,  and  the  fibula  a  double  fracture  at  about  the 
junction  of  the  middle  and  upper  thirds,  which  shows  a  de- 
flection of  the  middle  fragment  much  as  is  seen  in  the  above 
diagram.  Probably  both  the  tibia  and  fibula  were  broken  at 
the  same  time,  and  by  indirect  violence.  As  previously  stated, 
the  most  frequent  fracture  of  the  fibula  is  that  caused  by  a 
twist  of  the  ankle,  which  also  ruptures  the  internal  lateral  or 
deltoid  ligament, — a  strong  band  that  binds  the  inner  malleo- 
lus  down  to  the  bones  of  the  tarsus.  The  tibia  being  thus 
disengaged  from  its  connection  with  the  inner  ankle,  becomes 
16 


Fracture  of  the  fib- 
ula through  its 
upper  half;  show- 
ing deflection  of 
the  central  frag- 
ment. 


242 


FRACTURES. 


partially  dislocated.  This  complicated  injury,  from  having 
been  particularly  described  by  Mr.  Pott,  is  called  "  Pott's  frac- 
ture." His  words  are  as  follows :  "  I  have  already  said,  an. 3 


FIG.  102. 


it  will  obviously  appear  to 
every  one  who  has  examined 
it,  that  the  support,  of  the 
body,  and  the  due  and  proper 
use  and  execution  of  the  office 
of  the  ankle,  depend  almost 
entirely  on  the  perpendicular 
bearing  of  the  tibia  upon  the 
astragalus,  and  on  its  firm  con- 
nection with  the  fibula.  If 
either  of  these  be  perverted  or 
prevented,  so  that  the  former 
bone  is  forced  from  its  justand 
perpendicular  position  on  the 
astragalus  ;  or  if  it  be  separated 
by  violence  from  its  connection 
with  the  latter,  the  joint  of  the 
ankle  will  suiter  a  partial  dis- 
location internally;  which  par- 
tial dislocation  can  not  happen, 
without  not  only  a  considerable  extension  or  perhaps  lacera- 
tion of  the  bursal  ligament  of  the  joint,  which  is  lax  and 
weak,  but  a  laceration  of  those  strong  tendinous  bands,  which 
connect  the  lower  end  of  the  tibia  with  the  astragalus  and  os 
calcis,  and  which  constitute  in  a  great  measure  the  ligamen- 
tous  strength  of  the  joint  of  the  ankle.  This  is  the  case, 
when  by  leaping  or  jumping  the  fibula  breaks  in  the  weak 
part,  within  two  or  three  inches  of  its  lower  extremity." 

Strictly  in  accordance  with  Pott's  description,  a  simple  frac- 
ture of  the  fibula  through  its  lower  third,  whether  by  direct 
violence  or  other  force,  does  not  cover  all  the  lesion  he  has 
described.  In  other  words,  "  Pott's  fracture"  calls  for  lacera- 
tion of  the  internal  lateral  ligament,  and  partial  luxation  of 
the  tibia,  as  well  as  a  fracture  of  the  fibula  three  inches  above 
the  lower  extremity.  I  have  seen  the  fibula  fractured  through 
its  lower  third,  by  direct  violence  ;  and  the  astragalus  remained 
in  place,  and  the  deltoid  ligament  escaped  untorn  ;  and  I  have 
also  treated  cases  where  the  description  of  Pott  was  applicable 


"  Pott's  fracture,"  or  dislocation  of  the 
astragalus  from  the  tibia,  and  fracture  of 
the  fibula  above  the  ankle  joint. 


OF  THE  FIBULA. 


243 


so  far  as  the  broken  fibula  and  tibial  displacement  are  con- 
cerned, but  the  inner  malleolus  was  fractured  instead  of  there 
being  a  laceration  of  the  ligament  which  is  attached  to  that 
process  of  bone.  And  in  one  instance,  that  of  a  boy  of  six- 
teen who  had  a  splay  foot  and  lax  ligaments,  the  fibula  was 
broken  by  forcible  eversion  or  rotation  of  the  foot  outwards, 
and  the  tibial  part  of  the  articulation  remained  intact,  as  well 
as  the  ligamentous  structures  about  the  ankle  joint.  Still 
further,  the  fibula  has  been  broken  by  powerful  adduction  or 
inversion  of  the  foot,  the  bone  yielding  to  the  pressure  of  the 
astragalus  against  the  external  malleolus.  Malgaigne  affirms 
that  there  is  no  displacement  (luxation)  nor  laceration  of  lig- 
ament, external  or  internal,  when  the  fracture  is  caused  by  ex- 
treme adduction  ;  that  if  any  displacement  be.  found  it  is 
secondary,  being  produced  by  the  patient's  attempt  to  walk. 
However,  it  must  be  admitted  by  every  surgeon  conversant 
with  fractures,  that  in  a  large  proportion  of  cases  in  which 
the  fibula  is  broken  a  few  inches  above  the  external  malleolus, 

the  internal  lateral  ligament  is  rup- 
tured and  the  astragalus  more  or 
less  displaced  from  its  usual  junction 
with  the  lower  end  of  the  tibia. 
Pott  has  described  a  complicated 
lesion  that  occurs  in  more  than  half 
of  the  injuries  in  which  the  fibula  is 
broken  near  its  lower  extremity. 

Fracture  of  the  fibula  through  its 
lower  third  may  also  be  complicated 
with  a  dislocation  of  the  tarsus 
backwards.  A  person  in  falling 
from  a  height  may  strike  on  an  in- 
clined surface,  or  a  hard  substance 
that  keeps  the  heel  raised  ;  and  the 
force  caused  by  the  descent  continu- 
ing, dislocates  the  foot  backwards, 
and  breaks  the  fibula  a  few  inches 

above  the  ankle  by  a  lateral  or  twisting  motion.  In  such  an 
injury  the  lower  fragment  of  the  fibula  follows  the  bones  of 
the  tarsus,  and  abandons  all  contact  with  the  long  fragment. 
This  lesion  is  analogous  to  Pott's  fracture,  the  foot  being  dis- 
located backwards,  instead  of  outwards.  The  dislocation,  in 


Fracture  of  the  fibula  above  the  ankle, 


244  FRACTURES. 

both  cases,  is  the  leading  feature  of  the  injury.  The  foot, 
however,  can  be  quickly  replaced,  while  it  requires  several 
weeks'  treatment  to  secure  union  between  the  fragments  of  the 
fibula. 

The  symptoms  of  what  is  called  "  Pott's  fracture  "  are  quite 
marked  ;  yet  the  patient,  as  soon  as  the  injury  is  received,  often 
reaches  down  and  twists  the  foot  back  into  place,  thereby 
overcoming  those  prominent  signs  which  so  clearly  indicate 
the  nature  and  extent  of  this  complicated  lesion.  After  the 
foot  has  been  replaced  the  limb  appears  so  natural  in  contour 
that  the  inexperienced  practitioner  may  be  led  to  suppose 
that  no  serious  injury  exists.  I  was  once  called  to  see  Mr. 
Homau,  printer,  living  then  on  Elizabeth  Street,  who  had  re- 
ceived a  severe  twist  of  the  foot  by  having  it  caught  in  a 
crevice  of  the  sidewalk.  He  suffered  so  much  pain  that  he 
hired  a  passing  hackman  to  carry  him  home.  A  physician  of 
considerable  surgical  acquirements  was  called  ;  but  before  he 
arrived  the  patient  with  his  hand  had  overcome  the  distortion 
in  his  foot.  The  doctor  examined  the  ankle,  and  pronounced 
the  difficulty  a  sprain ;  he  visited  his  patient  every  day  for 
about  a  week,  and  ordered  a  lotion  which  was  prescribed  at 
his  first  visit,  to  be  continued.  Mr.  Homan  becoming  dissatis- 
fied with  the  progress  of  the  cure,  discharged  his  medical  at- 
tendant, and  invited  me  to  take  professional  charge  of  the 
case.  According  to  my  usual  custom  when  called  to  an  injury 
of  the  ankle,  I  carefully  hunted  for  fracture  of  the  fibula  just 
above  the  ankle.  There  was  much  swelling  about  the  joint ; 
and  it  was  apparent  when  the  two  limbs  were  compared,  that 
the  injured  leg  presented  a  little  greater  concavity  on  its  out- 
side, above  the  ankle,  than  the  other.  The  fingers  in  being 
pressed  along  the  course  of  the  fibula  discovered  at  the  point 
of  preternatural  concavity,  a  slight  irregularity  in  the  bone. 
Lateral  rocking  of  the  foot  produced  great  pain,  and  caused 
crepitus.  The  forced  rocking  of  the  foot  also  developed  mo- 
bility between  the  fragments,  which  the  finger  held  upon  the 
suspected  point  readily  discovered.  The  foot  could  bo  rocked 
outward  in  a  greater  degree  than  is  natural ;  and  when  once 
displaced  in  that  direction  it  was  inclined  to  stay  in  that 
position. 

In  an  ordinary  case  of  Pott's  fracture,  the  patient  not  having 
returned   the  foot  to  its  normal  position,  the  deformity  will 


OF  THE  FIBULA. 


245 


FIG.  104. 


appear  like  a  dislocation  of  the  foot  outwards,  though  such 
an  injury  can  not  exist  without  fracture  of  the  fibula.  The 
pain  and  swelling  are  noteworthy  signs,  though  not  sufficiently 
distinctive  in  their  character  to  establish  a  diagnosis.  The 
fractured  ends  of  the  fibula  will  be  driven  or  held  in  against 
the  tibia,  making  a  depression  at  the  point  of  fracture.  Per- 
sons having  bad  shaped  feet,  with  a  great  concavity  a  little 
above  the  ankle,  on  the  outside  of  the  leg,  and  with  the  ex- 
ternal malleolus  projecting  outward,  giving  great  width  to  the 
articulation,  are  prone  to  have  such  lax  deltoid  ligaments  that 
the  foot  can  hardly  be  kept  in  place  even  when  no  fracture 
exists.  A  weak  ankle  of  that  kind  makes  a  bad  recovery 
after  "  Pott's  fracture  ;"  and  the  result  is  far  from  satisfactory 
even  when  good  treatment  is  followed. 

TREATMENT  OF  FKACTURES  OF  THE  FIBULA.  —  A  fracture  of 
the  fibula,  not  connected  with  dislocation  of  the  foot,  may  be 
treated  with  a  common  lath  splint  laid  along 
the  outside  of  the  leg,  and  a  bandage  to  re- 
tain it  in  place.  No  shortening  of  the  limb 
can  occur,  nor  serious  displacement  of  any 
kind,  for  the  tibia  is  the  chief  bone  in  main- 
taining the  stability  of  the  leg.  A  patient 
with  a  fractured  fibula  above  the  lower  third 
of  the  bone,  can  walk  after  the  limb  is  dressed 
with  a  splint  and  bandage.  However,  it  is 
always  best  not  to  use  the  leg  except  with  the 
greatest  care,  and  with  the  aid  of  a  cane. 
The  fragments  need  to  be  kept  quietly  in  ap- 
position in  order  that  the  union  may  be 
osseous. 

Pott's  fracture  needs  a  skillfully  applied 
dressing.  After  the  reduction,  which  consists 
in  twisting  the  foot  into  its  natural  shape,  the 
leg  may  have  applied  to  its  inner  and  outer 
s^es  a  couple  of  lath  splints,  two  inches  or 
mol>e  wide>  and  lon£  enough  to  extend  from 
near  the  knee  to  the  sole  of  the  foot.  Under 
the  lower  end  of  the  outside  splint  a  firm  compress  is  to  be 
used  to  force  or  rock  the  foqt  inwards  when  the  roller  is  made 
to  perform  its  part  of  the  work.  The  outside  splint  bridges 


246 


FRACTURES. 


over  the  depression  which  exists  where  the  broken  ends  of 
the  fibula  are,  and  prevents  the  turns  of  the  circular  bandage 
from  dropping  into  it;  and  the  pressure  brought  to  bear  upon 
the  very  lowest  point  of  the  external  malleolus  tends  to  force 
the  broken  end  of  the  lower  fragment  away  from  the  tibia 
and  into  its  proper  position.  After  the  dressing  is  applied  the 
patient  may  walk  on  crutches,  using  the  maimed  limb  with  care. 
In  four  or  five  weeks,  consolidation  may  be  expected  to  take 
place.  The  limb  need  not  be  undressed  often  duringthe  treat- 
ment, for  the  fracture  generally  docs  well  if  properly  treated 
in  the  beginning.  No  leeches  or  fomentations  can  be  of  much 
service,  and  they  may  do  serious  harm.  Great  pain  may 
attend  the  injury  for  the  first  few  days,  yet  an  elevated  posi- 
tion of  the  leg,  and  an  easily  fitting  appliance  favor  a  state  of 
comfort  and  repose.  An  opiate  given  twice  a  day  while  the 
inflammation  continues,  keeps  the  patient  from  complaining. 
Any  large  blisters  charged  with  serum  may  be  pricked,  and 
excoriated  parts  kept  from  pressure. 

The  dressing  devised  by  Dupuytren,  in  his  own  language, 
"consists  of  a  cushion,  a  splint,  and  two  bandages.  The 
cushion,  made  of  cloth,  and  filled  two-thirds 
with  chaff,  should  be  two  feet  and  a  half  in 
length,  by  four  or  five  inches  in  width,  and 
three  or  four  thick.  The  splint,  from  eighteen 
to  twenty  inches  in  length,  two  inches  and  a 
half  wide,  and  three  or  tour  lines  thick,  should 
be  made  of  firm  and  slightly  flexible  wood. 
Lastly,  the  bandage  should  be  four  or  five 
yards  in  length.  The  cushion,  folded  upon  it- 
self in  the  form  of  a  wedge,  is  applied  to  the 
inner  side  of  the  fractured  limb,  and  laid  upon 
the  tibia,  its  base  directed  downwards,  being 
applied  upon  the  internal  malleolus,  not  pass- 
ing below  it  ;  its  apex  being  above  and  upon 
the  internal  condyle  of  the.  lemur.  The  splint 
applied  along  this  cushion  should  pass  below 
jf  from  four  to  six  inches,  and  extend  below 

lint  and 

th®  in»er  edge  of  the  foot  for  three  or  four 
inches.  These  first  pieces  of  the  apparatus  are 
fixed  to  the  upper  part  of  the  leg,  by  a  few  turns  of  bandage 
directed  from  above  downwards;  in  this  state  the  splint,  pro- 


105. 


pli 


OF  THE  FIBULA,  247 

longed  like  a  kiud  of  lever  below  the  base  of  the  cushion, 
leaves  between  it  and  the  foot  a  space  equal  to  the  thickness 
of  the  cushion,  that  is  to  say,  from  three  to  four  inches. 
This  extremity  of  the  splint  will  serve  as  a  'point  d'appni,' 
to  bring  the  foot  from  without  inwards.  For  this  purpose  the 
end  of  a  second  bandage  is  fixed  to  it,  and  then  directed  suc- 
cessively from  the  splint  over  the  upper  surface  of  the  foot, 
upon  its  outer  side,  under  the  sole  of  the  foot,  upon  the 
splint ;  then  from  this  upon  the  instep  and  under  the  heel,  to 
return  again  to  the  splint,  and  to  be  continued  in  the  same 
manner  until  all  the  bandage  is  used;  thus  embracing  in  the 
same  circles,  which  can  be  tightened  at  pleasure,  the  splint  and 
the  instep,  and  the  splint  and  the  heel  alternately.  The  foot 
is  brought  into  such  a  state  of  adduction  that  its  external 
edge  becomes  inferior,  the  sole  of  the  foot  directed  inwards, 
and  its  internal  edge  upwards." 

It  will  be  seen  by  the  diagram,  and  be  understood  by  the 
description,  that  the  dressing  of  Dupuytren  will  accomplish 
the  object  for  which  it  is  designed.  The  splint  is  a  lever,  the 
pad  a  fulcrum,  and  the  bandage  through  the  power  imparted 
to  it,  is  the  force  to  draw  the  foot  inwards ;  and  the  action  of 
the  lower  turns  of  the  roller  in  drawing  the  lower  end  of  the 
external  malleolus  inwards,  necessarily  tilts  the  broken  end 
outwards,  or  away  from  the  tibia,  the  space  in  the  vicinity  of 
the  fracture  being  purposely  left  bare  or  uncompressed.  So 
the  broken  ends,  whether  locked  against  one  another  or  not, 
may  be  left  unobstructed  to  return  to  their  normal  position. 

I  prefer  using  two  splints,  for  they  stay  in  place  better  than 
one,  and  constitute  an  even  and  firm  dressing  for  the  leg  and 
ankle  joint;  in  Dupuytreu's  dressing  his  upper  bandage  con- 
stricts the  leg  near  the  knee,  and  tends  to  press  the  lower  end 
of  the  long  fragment  into  the  interosseous  space.  In  the 
dressing  I  have  recommended,  a  compress  is  used  below  the 
external  malleolus,  large  enough  to  keep  the  outside  splint 
from  bearing  on  the  malleolus  itself;  and  another  compress 
on  the  inner  ankle  to  keep  the  inside  splint  from  pressing  on 
the  internal  malleolus,  and  to  allow  the  foot  to  be  rocked  in- 
wards without  hitting  the  splint.  There  is  no  necessity  for 
canting  the  foot  too  far  inwards  ;  an  excess  of  inversion  is  not 
desirable. 


248  FRACTURES 

In  cases  where  no  displacement  is  perceptible  I  dress  the 
ankle  with  pieces  of  pasteboard  and  a  bandage,  to  strengthen 
the  weakened  parts,  so  the  patient  may  hobble  about  with  the 
aid  of  a  cane  or  crutch.  I  have  seen  very  good  recoveries 
made  without  any  dressing. 

If  a  patient  recover  from  Pott's  fracture,  with  a  weak  ankle, 
he  can  derive  some  benefit  from  a  shoe  with  side  irons  fas- 
tened to  it,  such  as  is  worn  to  correct  weak  ankles  from  other 
causes.  Even  a  stiff  boot  or  brogan  lends  some  aid. 

In  the  case  of  Harry  Edwards,  who  in  a  leap  from  the  cars 
in  motion  near  Brighton  Station,  broke  both  bones  of  one  leg, 
and  the  fibula  a  little  above  the  ankle  joint  in  the  other,  I 
used  two  strips  of  adhesive  plaster  an  inch  wide  and  fourteen 
incbes  long,  to  treat  the  latter  fracture.  One  end  of  each  strip 
was  applied  to  the  outside  of  the  foot  and  ankle  ;  and  then 
the  two  strips  were  drawn  under  the  heel  and  sole,  and  while 
the  foot  was  twisted  inwards,  the  other  ends  of  the  adhesive 
plaster  were  applied  to  the  leg  on  its  inner  aspect.  Th ex- 
strips  prevented  the  foot  from  becoming  everted  ;  and  as  the 
patient  had  to  be  confined  to  his  bed  for  several  weeks  on  ac- 
count of  the  fractures  in  the  other  leg,  the  broken  fibula  con- 
solidated long  before  the  other  leg  was  well.  The  adhesive 
strips  accomplished  every  purpose  sought  in  a  more  compli- 
cated dressing. 

Potts'  fracture  is  exceedingly  common,  therefore  the  inex- 
perienced practitioner  should  study  its  every  phase.  As  miu-h 
may  be  said  of  all  fractures,  yet  the  most  frequent  lesions  are 
those  the  young  physician  should  study  h'rsr.  As  soon  as  a 
medical  man  has  had  a  few  fractures  of  the  leg  to  treat,  he 
studies  such  injuries  all  the  closer,  for  he  sees  how  important 
the  simplest  features  become.  Besides,  he  finds  that  good  re- 
salts  are  only  obtained  by  thoughtful  attention.  There  is  no 
such  thing  as  good  fortune  in  the  treatment  of  fractures  of 
the  leg.  Every  tendency  is  to  deformity  of  some  kind,  there- 
fore each  defect  and  distortion  is  to  he  provided  against  at 
repeated  dressing.  In  the  management  of  such  lesions,  the 
surgeon  can  not  afford  to  be  careless  or  in  a  hurry.  The  pa- 
tient's comfort  and  the  reputation  of  the  medical  attendant 
hinge  upon  the  application  of  sound  sense  to  every  part  of 
the  dressings. 


CHAPTER   XXVIII. 
FRACTURE  OF  THE   BONES  OF  THE  FOOT. 


The  anatomical  resemblance  between  the  hand  and  foot, 
necessitates  a  similarity  in  the  nature  of  the  injuries  peculiar 
to  both.  The  tarsal  bones  are  cuboid  in  shape,  and  contain  a 
large  proportion  of  spongy  material ;  therefore  they  are  sub- 
ject to  fracture  from  direct  violence  alone.  The  nature  of  the 
force  producing  a  fracture  of  one  of  these  bones  must  be  of  a 
crushing  character,  consequently  the  injury  done  to  the  soft 
parts  will  constitute  the  leading  feature  of  the  lesion.  The 
os  calcis  partakes,  to  a  certain  extent,  of  the  character  of  a 
long  bone.  At  any  rate,  its  projection  backwards  forms  the 
arm  of  a  lever  which  is  acted  upon  by  the  powerful  muscles 
of  the  calf  of  the  leg,  and  may  be  fractured  by  them.  The 
carpus  has  no  bone  which,  from  its  shape,  is  subject  to  great 
muscular  power.  The  astragalus,  situated  so  as  to  receive  the 
entire  articulation  of  the  lower  end  of  the  tibia,  is  necessarily 
subjected  to  immense  forces,  and  occasionally  crumbles  under 
their  influence.  These  two  bones,  then,  may  be  broken  by 
indirect  violence,  but  the  cuboid,  scaphoid  and  three  cuneiform 
bones  can  only  l>e  broken  by  the  fall  of  a  heavy  weight  upon 
them  or  by  the  passage  of  a  wheel  over  that  part  of  the  foot 
which  they  occupy.  The  fracture  can  hardly  be  simple  under 
these  circumstances,  for  the  force  must  bruise  the  soft  parts 
practically  to  the  extent  of  rendering  the  fracture  compound. 

The  os  calcis  in  a  heavy  person,  who  raises  himself  quickly 
upon  the  toes,  is  subjected  to  a  powerful  force,  though  the 
tendo  Achillis  is  more  likely  to  break  than  the  bone.  Either 
accident  must  be  extremely  rare,  for  few  surgeons  have  ever 
met  with  a  case.  The  projection  of  the  os  calcis  posteriorly 
exposes  the  bone  to  direct  violence.  A  miller  of  my  acquaint- 
ance had  his  right  os  calcis  broken  by  the  end  of  a  crowbar 

(249) 


250  FRACTURES. 

which  was  violently  hurled  by  the  full  of  a  log  from  a  wagon. 
He  wore  a  low  cut  shoe,  but  it  did  not  prevent  the  bar  from 
inflicting  upon  the  heel  a  telling  blow. 

The  astragalus  is  broken  by  a  thrust  of  the  tibia  again>t  it ; 
as  when  a  person  jumps  from  a  height  and  comes  to  the 
ground  with  the  tibia  placed  vertically  on  the  astragalus,  the 
shock  being  sufficient  to  split  or  crush  the  bone.  Mr.  Lous- 
dale  reports  a  case  of  the  kind  coming  under  his  observation  : 
"  The  patient  was  treated  for  a  severe  sprain,  there  being  no 
reason  to  suspect  fracture;  the  inflammation  of  the  joint, 
however,  was  so  great,  and  the  man's  constitution  became  so 
much  affected,  that  the  patient  died  on  the  twelfth  day.  The 
case  was  considered  peculiar,  from  the  severity  of  the  symp- 
toms ;  on  opening  the  joint,  however,  after  death,  the  astrag- 
alus was  found  to  be  split,  in  two  or  three  directions,  wliicli 
fully  accounted  for  the  constitutional  disturbance,  and  for  tin- 
other  serious  defects  produced  by  it."  An  isolated  fragment 
of  the  astragalus  could  not  well  escape  from  the  joint  without 
such  serious  disorganization  as  to  endanger  the  articulation, 
to  say  nothing  of  perils  to  life. 

In  fractures  of  the  os  calcis,  the  strong  plantar  fascia  pre- 
vents the  disengaged  fragment  from  being  drawn  far  upwanU 
by  the  gasirocnemius  and  soleus  muscles,  though  surgical 
writers  speak  t  about  the  separated  piece  being  drawn  upwards 
several  inches.  In  the  case  of  Mr.  Conklin,  the  miller,  whose 
heel  bone  was  broken  by  the  iron  bar,  there  was  no  marked 
separation  of  fragments,  but  the  fullness  in  what  is  termed 
the  hollow  of  the  foot,  was  marked,  and  the  heel  seemed  to 
be  elongated.  Manipulation  discovered  mobility  and  crcpitus. 
The  pain  and  swelling  were  considerable,  though  the  patient 
claimed  that  the  contusion  produced  by  the  missile,  Avas  the 
chief  cause  of  the  distress.  The  inability  to  walk  was  mani- 
fest as  soon  as  an  effort  was  made  to  take  a  step. 

The  treatment  adopted  in  that  case  maybe  applicable  in  all 
similar  cases.  While  the  foot  was  moderately  extended  it 
was  encased  in  strips  of  adhesive  plaster  until  every  part  was 
covered  in;  then  two  long  -trips  were  attached  to  the  top  of 
the  instep  by  their  lower  ends,  and  then  extended  down  on 
each  side  of  the  foot,  to  the  sole  where  they  crossed  each 
other  and  came  up  on  each  side  of  the  heel  and  so  on  to  th<> 
calf  of  the  leg  where  they  weie  mad-'  to  adhere.  Thc-e  kept 


OF  THE  BONES  OF  THE  FOOT.  '  251 

the  foot  in  a  state  of  extension.  The  knee  was  flexed  over 
pillows,  and  the  limb  was  kept  in  a  state  of  comparative 
repose  for  several  weeks.  The  consolidation  was  complete, 
thouo-h  the  functions  of  the  foot  remained  somewhat  im- 

O 

paired.  Tho  point  of  the  heel  appeared  to  be  raised  a  half 
inch  or  so. 

The  kind  of  apparatus  commonly  recommended  is  a  slipper- 
like  toe-piece  nailed  to  a  wooden  sole  or  foot-board  as  a  base 
for  the  application  of  mechanical  forces;  a  pad  is  placed  just 
above  the  heel,  which  has  a  long  strap  attached  to  it ;  this  is 
first  carried  down  through  a  ring  in  the  wooden  sole,  through 
which  it  acts  like  the  cord  of  a  pulley,  and  then  extends  above 
the  calf  of  the  leg  where  it  is  confined  by  the  circular  turns 
of  a  bandage.  The  appliance  is  not  equal  in  merit  to  the  ad- 
hesive strip  contrivance  just  described. 

Fractures  of  the  other  tarsal  bones  admit  of  no  apparatus 
to  overcome  displacement,  and  to  prevent  mobility ;  but  the 
injury  is  to  be  treated  like  other  severe  injuries  of  the  foot, 
no  special  regard  being  paid  to  the  fragmentary  state  of  one 
or  more  of  the  bones.  The  inflammation  and  suppuration  are 
to  be  managed  on  the  general  principles  involved  in  the  treat- 
ment of  wounds.  Amputation  is  required  sooner  or  later  in 
some  of  the  worst  cases,  though  a  laying  open  of  the  foot  and 
the  removal  of  isolated  and  carious  fragments  njay  save  life 
and  a  more  or  less  useful  foot. 

The  metatarsal  bones  are  less  exposed  and  more  exempt 
from  fractures  than  the  corresponding  bones  in  the  hand. 
The  forces  which  break  the  metatarsal  bones  are  the  passage 
of  a  wheel,  and  the  fall  of  heavy  weights.  Hermann  Frieling, 
while  removing  a  safe  on  Third  Street,  had  his  foot  caught 
between  the  side  of  the  safe  and  the  door  post,  and  received 
a  fracture  of  the  three  outer  metatarsal  bones.  He  was  carried 
home,  and  the  boot  was  cut  from  his  foot  before  I  saw  him. 
Swelling  and  discoloration  marked  the  line  where  the  sharp 
corner  of  the  safe  had  pinched  his  foot.  Crepitation  was 
elicited  by  manipulation;  there  was  no  displacement  discover- 
able. I  placed  a  compress  on  the  sole  against  the  seat  of  in- 
jury and  bandaged  the  foot.  In  ten  days  he  walked  upon  hia 
heel,  with  the  assistance  of  a  cane  ;  and  entirely  recovered, 
without  deformity  or  defect,  in  five  or  six  weeks  from  the  re- 
ception of  the  injury. 


252  FRACTURES. 

The  fragments,  after  fracture  of  the  metatarsal  bones,  are 
liable  to  project  upwards,  though  the  direction  they  take  de- 
pends somewhat  upon  the  force  whicli  produced  the  injury. 
If  the  healing  process  takes  place  with  the  ends  of  the  frag- 
ments projecting  upwards,  the  salient  points  are  constant 
sources  of  irritation  from  the  pressure  of  the  boot  or  shoe ; 
und  if  they  sink  downwards,  so  as  to  produce  a  prominence 
on  the  sole  of  the  foot,  the  defect  is  still  worse,  for  the  points 
pressed  upon  in  walking  will  be  constantly  tender.  The  pha- 
langes of  the  toes  are  seldom  broken.  The  first  phalanx  of 
the  great  toe  is  fractured  more  frequently  than  the  bones  of 
all  the  other  toes  taken  together.  The  fall  of  a  heavy  weight 
upon  the  great  toe,  or  direct  violence  quickly  applied,  is  gen- 
erally the  cause  of  fracture  of  this  digit.  The  other  toes  are 
so  small  and  yielding  that  they  commonly  escape  fracture 
though  the  great  toe  be  caught  and  broken. 

The  signs  of  fracture  in  the  first  phalanx  of  the  great  toe 
are  sufficiently  marked  for  ready  recognition.  The  displace- 
ment is  generally  inconsiderable,  but  mobility  and  crepitus 
can  be  elicited. 

The  treatment  for  fracture  of  the  great  toe  consists  in  bind- 
ing a  splint  to  its  under  surface,  and  keeping  the  foot  at  rest 
during  the  period  of  reparation.  Lonsdale  says  that  fractures 
of  the  great  toe  are  attended  with  great  irritation,  which 
affects  the  absorbents  all  the  way  to  the  groin,  causing  ab- 
scesses to  form  in  different  parts  of  the  limb,  and  producing 
great  constitutional  disturbance.  Probably  these  complica- 
tions arise  from  the  contusion  which  is  apt  to  be  severe  when 
a  toe  is  broken.  Bruises  of  the  great  toe,  if  followed  by  deep 
suppuration,  are  attended  with  constitutional  disturbances 
whether  the  phalanges  be  broken  or  not. 


P^RT    II. 

DISLOCATIONS 


DISLOCATIONS. 


CHAPTER   [. 
GENERAL  CONSIDERATIONS 


The  term  Dislocation,  or  luxation,  is  employed  to  signify 
the  sudden  and  forcible  separation  of  the  articular  surfaces  of 
two  or  more  bones.  The  displacement  is  commonly  caused 
by  accidental  violence,' and  is  generally  attended  with  lacera- 
tion of  the  surrounding  ligamentous  and  connective  tissues. 

Dislocations  are  injuries  of  frequent  occurrence,  and,  if 
allowed  to  remain  unreduced,  they  constitute  a  serious  and 
lasting  class  of  deformities  ;  consequently  the  practitioner  of 
medicine  and  surgery,  who  holds  himself  in  readiness  to 
assume  the  responsibilities  of  such  lesions  must  give  the  sub- 
ject of  luxations  a  vast  amount  of  careful  study,  or  he  will 
inflict  permanent  lameness  upon  those  so  unfortunate  as  to 
call  for  his  services.  Almost  all  physicians  are  ambitious  to 
attend  to  surgical  cases  on  account  of  the  eclat  arising  from  a 
quickly  performed  operation  ;  but  in  order  to  accomplish  sat- 
isfactorily all  their  laudable  aspirations  may  crave,  intense 
thought  must  be  given  to  the  mechanism  and  pathology  of 
the  joints.  There  is  no  such  anomaly  as  a  "  natural  bone 
setter,"  any  more  than  there  is  a  natural  engineer  or  watch 
repairer.  A  man  may  have  a  love  for  the  principles  involved 
in  nicely  constructed  machinery,  and  a  desire  to  become  a 
practical  machinist, — a  love  and  desire  which  constitute 
genius,  but  the  possessor  is  not  a  finished  artisan  until  he  can 
practically  apply  the  principles  of  the  art  or  science — an  at- 
tainment which  is  the  result  of  prolonged  study  and  persever- 
ing toil  ;  a  young  man  may  feel  an  intense  longing  to  master 
a  ship,  and  study  navigation  for  that  purpose,  which  is  a  pre- 

(255) 


256  DISLOCATIONS. 

requisite  to  success,  but  he  will  never  find  the  capitalist  who 
will  entrust  a  valuable  cargo  to  his  care  until  he  has  crossed 
tlie  seas  and  learned  the  winds  aud  the  seasons,  the  currents 
and  counter-currents  of  the  ocean,  and  something  of  the  varied 
influences  known  only  to  the  practical  navigator.  Any  claims 
for  natural  gifts  in  navigation  would  be  treated  with  con- 
tempt. 

A  few  individuals  have  gotten  the  credit  of  being  natural 
bone  setters,  but  their  merits,  so  far  as  they  go,  depend  more 
upon  tact  than  skill ;  and  the  prevailing  credulity  of  th<f  peo- 
ple has  given  them  more  reputation  for  ability  than  might 
reasonably  be  expected  from  their  limited  success.  A  family 
by  the  name  of  Whitworth,  in  England,  and  another  by  the 
name  of  Sweet,  in  Connecticut,  have  assumed  to  possess  the.se 
wonderful  inborn  qualities.  For  two  or  three  generations, 
one  or  more  of  the  male  members  of  these  families  claimed 
to  possess  a  secret  power  for  reducing  dislocated  bones  ;  ami 
not  a  few  persons  of  average  intelligence  give  credence  to 
these  preposterous  assumptions.  Any  uneducated  man  with 
a  large  endowment  of  boldness  and  self  assurance,  claiming 
to  be  a  natural  bone  setter,  could  by  giving  everv  distorted 
joint  coming  in  his  way,  a  severe  pulling  and  twisting, 
accomplish  some  cures ;  the  successes  would  be  heralded  far 
and  near,  and  the  failures  would  pass  unmentioned  and  unrc- 
membered,  consequently  he  would  soon  gain  considerable  ex- 
perience in  handling  defective  joints,  and  if  he  proved  to  be  a 
good  learner  he  would  acquire  considerable  skill  in  his  pre- 
tended art.  Having  received  no  lessons  in  anatomy  and  sur- 
gery, success  even  in  a  single  case  would  be  accepted  by  the 
popular  mind  as  positive  evidence  of  innate  powers.  Love  of 
the  marvellous  is  so  infatuating  that  every  age  will  have  to 
endure  its  quota  of  imposters.  However,  it  is  not  to  be 
denied  that  these  charlatans  have  done  some  good  indirectly. 
The  fact  that  a  dislocated  bone  could  be  reduced  by  manipu- 
lation, without  the  aid  of  pulleys  and  other  instruments  for 
multiplying  force,  led  such  discreet  surgeons  as  Dr.  Nathan 
Smith,  to  put  the  manipulating  plan  into  successful  practice.* 

The  Whitworths,  Sweets,  and  others  of  their  order,  studi- 
ously keep   to   themselves   their  plan  of   operating,  though 

*Soe  "Surgical  Memoirs  of  Dr.  Nathan  Smith,"  by  his  son,  Dr.  Nathan  R. 
Smith,  of  Baltimore. 


DISLOCATIONS.  -2b~ 

competent  observers  declare  that  it  is  not  essentially  different 
from  the  plan  now  followed  by  the  most  intelligent  portion 
of  the  profession.  Being  aware  of  their  general  incompetency 
iii  surgical  science,  these  "  natural  bone  setters'"'  preferred  to 
keep  secret  the  little  knowledge  they  possessed,  hoping  to  re- 
tain this  meagre  advantage  over  those  who  in  every  other 
respect  were  their  superiors.  Probably  a  similar  feeling  actu- 
ated the  Chamberlains  to  keep  as  a  secret  in  their  family  a 
knowledge  of  the  obstetric  forcep.  Such  detested  seltishn.  — . 
by  a  law  as  unvarying  as  that  of  gravitation,  will  taint  tin- 
name  of  those  who  in  an}-  branch  of  the  healing  art,  withhold 
knowledge  which  accident  or  genius  has  placed  within  their 
power.  Anything  in  medicine  or  surgery  which  will  benefit 
our  fellow  men  ought  to  be  the  common  property  of  mankind  ; 
and  he  possesses  a  sordid  spirit  who  from  seltish  motives  will 
not  promulgate  a  secret  which  will  ameliorate  the  condition 
of  the  unfortunate.  The  dabbler  in  secrets  is,  by  the  common 
consent  of  all  good  men,  branded  indelibly  with  the  disgrace 
that  cleaves  to  the  quack  and  the  charlatan. 

The  manipulating  plan  of  reducing  dislocations  is  now  well 
understood  by  those  having  a  knowledge  of  the  anatomy  of 
the  joints,  and  of  the  muscles,  ligaments,  and  other  struc- 
tures involved  in  a  luxation. 

The  use  of  anaesthetics  in  overcoming  the  rigidity  of  dislo- 
caivd  limbs,  has  also  contributed  to  overthrow  the  old  method 
of  replacing  a  displaced  bone  by  mechanical  violence.  In  the 
present  advanced  stage  of  knowledge  pertaining  to  disloca- 
tions there  is  little  use  for  the  pulleys,  straps,  hooks,  and  other 
appliances  so  indispensable  a  half  century  ago ;  and  it  is  to  be 
hoped  that  knowledge  will  still  further  advance,  so  that  these 
contrivances  shall  be  looked  upon  more  as  objects  of  curiosity 
and  implements  of  torture  than  as  the  appliances  of  an  en- 
lightened profession ;  and  that  the  cruelties  practiced  with  them 
will  be  associated  with  those  of  the  old  Spanish  Inquisitions. 

It  seems  a  pity  that  somebody  before  Dr.  Nathan  Smith's 
time  did  not  take  a  hint  from  the  Whitworths  or  Sweets,  and 
study  out  and  put  in  practice  a  principle  of  reduction  in  dis- 
locations which  was  demonstrated  by  those  charlatans  to  have 
an  existence.  Perhaps  the  spirit  of  the  profession  was  too 
arrogant  to  receive  suggestions  from  such  a  source.  Unfor- 
tunately for  the  world,  good  ideas  arc  often  kept  from  seeing 
17 


258  DISLOCATIONS. 

the   light   on    account   of  the   illiberality  of  the    inftueutia1 
classes. 

The  joints  are  generally  encased  in  capsular  ligaments ;  at 
some  point  there  maybe  a  thickening  and  a  strengthening  of 
the  ligamentous  tissues,  and  this  augmentation  may  receive 
the  designation  of  a  distinct  band  of  libers,  yet  these  several 
ligaments,  as  the  anterior,  posterior,  and  internal  and  external 
lateral,  generally  go  to  make  up  one  continuous  structure 
which  encloses  the  entire  articulation.  In  nearly  all  instances 
of  dislocation  this  ligamentous  bag  or  capsule  is  torn  by  the 
force  that  displaces  the  bone;  in  rare  cases  the  ligament 
stretches  sufficiently  to  allow  the  bone  to  remain  partially  dis- 
placed. The  bone,  after  it  has  been  forced  through  a  rent  in 
the  capsule,  is  often  dragged  away  from  the  opening,  or  so 
twisted  by  muscular  contraction  that  it  is  no  longer  in  a  fav- 
orable position  to  return  through  the  laceration.  This  is  par- 
ticularly the  case  with  the  shoulder  and  hip  joints.  But  it' 
the  limb  be  carried  to  the  attitude  it  was  forcibly  made  to  as 
sume  when,  the  head  of  the  bone  escaped  from  the  socket,  the 
part  protruding  through  the  capsule  will  be  in  a  favorable  po- 
sition to  return.  In  attempts  to  reduce  dislocations  of  the 
hip  and  shoulder  the  surgeon  must  seek  to  get  the  limb  into 
that  attitude  ;  and  if  he  succeeds,  very  little  force  will  be  re- 
quired to  complete  the  reduction.  Direct  violence  rarely 
knocks  a  bone  out  of  place ;  dislocations  are  generally  pro- 
duced by  forces  acting  upon  the  displaced  bone  as  a  lever, 
some  portion  of  the  articular  structures  performing  the  part  of 
a  fulcrum.  Muscular  force  assists  in  producing  dislocations, 
and  the  power  continuing  prevents  the  return  of  the  bone  to 
its  normal  position.  However,  the  antagonistic  muscles,  if 
given  an  opportunity  to  act  advantageously,  assist  in  all  ra- 
tional attempts  at  reduction.  A  proper  appreciation  of  the 
construction  of  joints,  and  of  the  functions  of  muscles  and 
other  tissues  surrounding  them,  has  created  a  revolution  in 
the  art  of  reducing  luxations.  In  the  "  Surgical  Observa- 
tions" of  Dr.  J.  Mason  Warren,  page  354,  the  revolution  is 
acknowledged  to  the  following  extent :  "  The  use  of  ether  has 
made  a  very  great  change  in  the  practice  pursued  in  the  treat- 
ment of  dislocations  of  the  hip,  which  can  now  be  very  fre- 
quently reduced  by  normal  assistance  only,  thus  enabling  us, 
in  many  cases,  to  dispense  entirely  with  pulleys ;  and,  by 


DISLOCATIONS.  250 

successive  movements  of  flexion,  abduction,  and  rotation,  to 
restore  the  head  of  the  hone  to  its  socket  with  remarkable 
facility."  This  is  an  acknowledgment  from  high  authority  in 
regard  to  a  joint  which,  when  dislocated,  once  called  for  ex- 
tending apparatus  of  the  most  powerful  kind.  Dr.  W.  \V. 
Reid,  of  Rochester,  N.  Y.,  who  has  written  out  an  exceed- 
ingly clear  plan  for  reducing  dislocations  of  the  femur  by 
manipulation,  says,  in  concluding  his  paper  on  the  subject  : 
"  Dislocation  of  the  hip  on  the  rlorsum  Hit,  an  accident  so 
serious  to  the  patient,  and  so  formidable  to  all  surgeons,  is  re- 
duced with  the  greatest  ease,  in  a  few  minutes,  without  much 
pain,  without  an  assistant,  without  pulleys,  without  '  Jarvis' 
Adjuster,'  or  any  other  mechanical  means,  simply  by  flexing 
the  leg  upon  the  thigh,  carrying  the  thigh  over  the  sound  one, 
upward  over  the  pelvis,  as  high  as  the  umbilicus,  and  then  by 
abducting  and  rotating  it."  Dr.  Reid  has  succeeded  in  reduc- 
ing dislocations  of  the  femur  in  several  instances  by  the 
"  natural  plan,"  and  therefore  does  not  speak  from  a  theoret- 
ical point  of  view  alone.  The  plan  has  been  carried  into  suc- 
cessful operation  by  a  great  number  of  surgeons,  and  always 
without  failure  when  Dr.  Reid's  rules  were  followed.  Jarvis' 
Adjuster,  once  so  popular  that  the  inventor  could  hardly  fill 
orders  as  fast  as  they  were  given,  has  gone  almost  entirely 
out  of  use,  and  young  surgeons  rarely  indulge  in  the  expense 
of  a  set  of  pulleys.  In  my  own  practice  I  have  found  no  case 
of  recent  dislocation  that  could  not  readily  be  reduced  by 
manipulation,  under  chloroform.  Our  older  works  on  dislo- 
cations, from  Cooper  to  Hamilton,  have  a  great  display  of  il- 
lustrations to  show  how  the  pulleys  should  be  applied  in  efforts 
to  reduce  luxations  of  the  hip  and  shoulder,  }ret  there  is  rarely, 
if  ever,  a  necessity  for  following  those  directions.  Perhaps 
the  publishers  of  modern  surgical  works,  whose  illustrations 
belong  mostly  to  the  past,  have  been  ambitious  to  make  a 
numerical  display  of  cuts,  caring  little  whether  they  contrib- 
uted to  perpetuate  a  fundamental  error  in  practice  or  not. 
Dr.  Reid,  in  his  essay,  read  at  the  annual  meeting  of  the  Mon- 
roe County  Medical  Society,  in  May,  1850,  says,  "Having  wit- 
nessed, on  several  occasions,  the  inquisitorial  torture  inflicted 
upon  the  unfortunate  patients — their  screeching — their  piteous 
begging  to  be  released— the  slipping  of  bandages — the  yield- 
ing and  re-adjusting  of  fixtures — the  delay — the  duration  of 


DISLOCATIONS. 

the  operation,  sometimes  two  or  three  hours, — the  exhaustion 
of  the  patient,  and  after  all,  in  some  instances,  a  failure,  and 
the  patient  a  cripple  for  life,  a  profound  horror  and  prejudice 
against  the  use  of  pulleys  seized  me  (Jarvis'  Adjuster  had  not 
then  been  invented),  and  I  could  not  avoid  the  conviction  that 
a  great  power  was  unnecessary,  and  that  it  must  he  misap- 
plied. Preceptors,  professors  and  authors  were  interrogated. 
The  unanimous  reply  to  all  my  queries  was — '  to  overcome  the 
contraction  of  the  great  muscles,  which  drew  up  and  short- 
ened the  limb,  viz.,  the  glutei,  triceps  femoris,  the  iliacus  in- 
ternus  and  psoas  magnus.'  But  do  these  same  powerful  mus- 
cles contract,  and  shorten  the  limb  when  there  is  fracture  in 
the  neck  of  the  femur?  Yes.  And  you  tell  me  that  one  of 
the  diagnostic  symptoms  between  fracture  and  dislocation  on 
the  dorsum  is,  that  in  fracture  the  limb  can  be  easily  extended 
to  its  normal  length,  by  the  strength  of  one  man,  while  in 
luxation  it  can  not.  Now  why  do  these  great  muselvs  require 
so  much  more  force  to  overcome  them  in  one  case  than  in  the 
other?  To  this  I  could  get  no  satisfactory  or  even  plausible 
reply."  ^ 

It  will  be  seen  that  Dr.  Reid  looks  upon  the  mechanical 
method  of  reducing  dislocations  of  the  hip  as  senseless  in  the 
extreme;  and  indicates  a  physiological  plan  which  consists  in 
giving  the  limb  an  attitude  which  relaxes  the  muscles,  and 
places  the  bone  iu  a  position,  favorable  to  a  return  through  the 
laceration  in  the  capsule.  To  pull  the  limb  straight  down- 
wards, as  is  done  by  mechanical  appliances,  renders  some  of 
the  muscles  rigidly  tense,  and  constricts  the  neck  of  the  bone 
with  the  untorn  portion  of  the  capsular  ligament. 

Every  joint  not  being  ball  and  socket,  like  the  shoulder  and 
hip,  the  same  kind  of  manipulation  will  not  succeed  with 
them  when  dislocated,  yet  the  principle  of  placing  a  bone  in 
the  exact  attitude  in  which  displacement  was  effected,  is  the 
position  favorable  to  reduction.  For  instance,  the  first  pha- 
lanx of  the  thumb  is  dislocated  backwards  by  a  force  which 
throws  it  into  extreme  flexion,  the  bone  being  a  lever  to  tear 
the  capsular  ligament,  and  the  muscles  a  secondary  force  to 
draw  it  back  after  the  usual  points  of  resistance  are  overcome. 
The  bone  having  been  dislocated  while  in  extreme  flexion,  re- 
turns to  nearly  its  normal  attitude  as  soon  as  the  flexing  force 
is  removed,  for  the  projecting  articular  rim  has  dropped  into 


DISLOCATIONS.  261 

a  depression  behind  the  head  of  the  metacarpal  bone.  Now, 
to  make  extension  straight  forward  would  not  effect  reduction 
unless  the  force  he  great  enough  to  rupture  the  yet  untorii 
portion  of  the  ligament  which  is  rendered  tense  by  the  dis- 
placement of  the  phalanx.  But  if  the  thumb  be  carried  into 
extreme  flexion,  where  it  was  when  luxation  took  place,  the 
projecting  rim  is  lifted  from  the  depression  spoken  of,  the  un- 
toru  portion  of  the  ligament  is  relaxed,  and  everything  is 
made  ready  for  the  reducing  manoeuvre,  which  consists  in  the 
operator  placing  his  thumb  tirmly  behind  the  displaced  pha- 
lanx where  it  is  to  perform  the  part  of  a  fulcrum,  while  the 
dislocated  thumb  is  used  as  a  lever  to  pry  the  displaced  bone 
into  its  normal  position. 

In  the  upper  extremity  the  bone  nearest  the  trunk  is  re- 
garded by  all  authors  as  the  one  from  which  the  distal  bone 
is  dislocated  ;  for  instance,  the  hnmerns  is  dislocated  from  the 
scapula,  the  radius  and  ulna  from  the  humerus,  and  so  on,  but 
in  the  lower  extremity  the  rule  is  not  maintained  by  all;  the 
femur  is  regarded  as  dislocated  from  the  acetabulnm,  and  the 
tibia  from  the  femur,  but  several  authors  have  changed  the 
rule  so  far  as  the  tibio-tarsal  articulation  is  concerned. 
Cooper,  Malgaigne,  Hamilton,  Gross,  and  others,  regard  dis- 
locations of  the  ankle  as  displacements  of  the  tibia  forwards, 
backwards,  etc.  On  the  contrary,  man}'  prominent  French, 
English,  and  German  surgeons,  adhere  to  the  rule  as  applied 
to  other  joints,  and  speak  of  dislocations  of  the  foot  when 
the  luxation  is  at  the  ankle. 

There  seems  to  be  no  valid  reason  for  this  exception  to  a 
rule  that  ought  to  be  general ;  and  it  would  have  been  credit- 
able in  Hamilton,  Gross,  and  other  American  surgical  writers. 
if  they  had  lent  their  great  influence  toward  correcting  this 
manifest  error  in  the  manner  of  considering  the  subject. 

Dislocations  need  to  be  considered  in  a  variety  of  aspects  ; 
they  have  been  divided  into  congenital  and  traumatic  as  gen- 
eral classes;  and  subdivided  into  the  simple,  compound,  com- 
plicated, partial,  complete,  recent,  ancient,  primitive,  and  con- 
secutive. 

Congenital  dislocation  is  a  lesion  intimately  connected 
with  malformations  and  detects  of  childhood,  and  does  not 
legitimately  belong  to  that  great  class  of  accidents  ordinarily 
embraced  under  the  head  <>f  luxations.  Kobert  Smith,  of 


262  DISLOCATIONS. 

Dublin,  reports  a  case  of  congenital, dislocation  of  the  jaw,  io 
an  idiot,  and  states  that  the  upper  ja\v  projected  beyond  the 
the  lower,  and  the  month  could  be  freely  opened  and  closed; 
tin-  reverse  order  of  signs  is  observed  in  accidental  luxations  of 
that  bone.  Certain  dislocations  of  the  shoulder  seen  in  young 
subjects  are  occasionally  not  complete  luxations,  but  partial 
displacements  arising  from  paralysis  or  irregular  muscular 
con  tractions.  Dupuytren  looked  upon  these  defects  of  the 
shoulder-joint  as  the  result  of  arrested  development  in  the 
bones  constituting  the  articulation,  the  socket  being  mostly 
at  fault.  Chelius  and  Cruveilhier  ascribe  them  to  the  position 
of  the  fcetns  in  the  womb.  Guerin  considers  them  as  the  pro- 
duet  of  an  active  or  primary  retraction  of  the  muscles,  the 
remote  cause  of  which  is  to  be  sought  in  the  affection  of  some 
central  part  of  the  nervous  system  ;  and  that  they  result  from 
the  same  causes  as  club-foot,  wry-neck,  etc.  I  have  seen  a 
partial  dislocation  of  the  head  of  the  radius,  congenital  in 
character,  in  a  bright  little  girl  having  no  other  defects,  ex- 
cepting that  one.  The  entire  elbow  joint  was  considerably 
involved  in  the  imperfect  development  which  permitted  the 
luxation.  By  the  fifteenth  year  the  arm  so  far  recovered, 
without  treatment,  that  the  limb  was  as  useful  as  the  other, 
and  no  apparent  deformity  existed. 

Robert  Smith  reports  several  congenital  dislocations  of  the 
wrist,  in  which  there  was  defective  development  of  the  arm 
bones,  and  distortions  of  the  carpus.  1 1  is  observations  were 
founded  upon  dissections  ;  and  he  criticises  the  speculations 
of  Dupuytren  and  Cruveilhier  in  regard  to  cases  of  theirs 
which  they  regarded  as  the  result  of  epiphyseal  injury.  A 
certain  preternatural  laxity  of  the  soft  tissues,  brought  about 
in  some  instances  by  nervous  disorders,  and  faulty  nutrition 
is  found  in  these  cases  of  congenital  luxations  of  the  wrist, 
as  well  as  of  soaie  of  the  other  joints  ;  and  a  large  share  of 
which  will  improve  by  growth  and  age.  Some  of  these  cases 
are  not  true  dislocations,  but  partial  luxations  arising  from 
extreme  flexion  and  extension. 

Congenital  dislocations  of  the  femur  are  occasionally  met  in 
defective  organizations,  or  as  Cruveilhier  >ay>.  vices  </<•  <-nnj'<>r- 
mntion.  He  found  in  .one  case,  in  connection  with  dub-feet 
and  club-hands,  a  congenital  luxation  of  both  thigh  bones; 
the  fetus  died  at  birth,  and  was  found  to  be  without,  kidney* 


DISLOCATIONS.  26:3 

and  testes,  and  marked  with  other  dcficienees ;  the  heads  of 
the  thigh  bones  were  flattened,  and  the  cotyloid  cavities  were 
shallow. 

Dr.  J.  M.  Carnoehan,  who  has  given  considerable  attention 
to  infantile  deficiences,  says  that  "  Congenital  defects  occur- 
ring in  the  ilio-femoral  articulation  result  from. active  morbid 
muscular  retraction  ;  that  morbid  muscular  retraction  itself  is 
to  be  traced  to  a  morbid  condition  of  the  central  ganglionic 
mass  of  the  cord  ;  and  this  pathological  condition  is  either 
located  in  the  ganglionic  mass,  or  conveyed  thither  by  the  in- 
cident-excitor  nervous  influence  of  the  excito-motor  apparatus 
of  the  medulla  spinalis."  This  is  not  given  with  Prof.  Car- 
nochan's  usual  perspicuity. 

The  gait  in  congenital  dislocation  of  the  thigh  on  both 
sides,  is  peculiar  and  unmistakable ;  no  other  motion  is  like 
that  which  is  occasioned  by  this  lesion  :  it  is  a  rolling  motion 
of  the  trunk  together  with  double  lameness;  and  yet  it  is 
painless  and  rapid.  In  some  instances  the  nervous  defect  is 
so  great  that  the  individual  is  compelled  to  move  about  in  a 
go-cart,  being  unable  to  balance  the  body  and  move  the  limbs 
with  any  degree  of  certainty. 

Congenital  dislocations  of  the  knee  are  generally  sub-luxa- 
tions resulting  from  abnormal  muscular  contractions  ;  and,  to 
l»e  substantially  benefited,  require  subcutaneous  section  of  the 
ham-string  tendons,  and  mechanical  extension  of  the  limbs. 

Partial  dislocation  of  the  ankle,  as  a  congenital  defect,  is  a 
species  of  "  weak-ankle,"  the  ligamentous  and  fibrous  tissues 
being  too  lax  or  undeveloped  to  sustain  the  lateral  strain  ne- 
cessary to  a  firm  joint.  The  foot  seems  to  be  affected  with  a 
variety  of  talipes,  and  flaps  about  with  much  uncertainty.  A 
shoe  with  side  irons  extending  up  the  leg,  and  fastened  to  the 
limb  with  a  hoop  and  strap,  affords  some  relief,  and  assists  in 
a  cure  or  substantial  improvement. 

Congenital  dislocations,  from  what  has  just  been  said  of 
them,  are  to  be  looked  upon  as  the  result  of  arrested  or  per- 
verted development,  and  are  not,  except  in  rare  instances,  to 
be  treated  by  a  process  of  rapid  reduction,  like  those  luxations 
that  occur  suddenly  from  accident. 

Ti'<i.tnnatw  dislocations  arc  the  forcible  separation  of  the  ar- 
ticular surfaces  of  two  or  more  bones,  in  which  the  loss  of 
p«»\ver  is  instantaneous,  and  the  luxated  part  is  excessively 


264  DISLOCATIONS. 

rigid.  The  names  of  the  varieties  have  already  been  given. 
A  simple  luxation  is  unaccompanied  with  serious  complica- 
tions, though  there  is  generally  a  rupture  of  the  ligamentous 
structures.  It  may  be  caused  by  external  violence,  and  mus- 
cular contraction.  The  humerus  is  often  dislocated  by  the  ac- 
tion of  the  muscles  only.  A  convulsive  condition  ha&  been 
known  to  produce  dislocation  of  several  of  the  joints.  The 
term  compound  is  applied  to  a  dislocation,  in  connection  with 
which  the  displaced  bone  is  forced  through  the  flesh  and  skin, 
or  an  opening  is  made  in  some  other  way,  communicating 
with  the  cavity  of  the  articulation. 

A  complicated  dislocation  is  one  in  which  there  is  a  more  ex- 
tensive lesion  than  simple  displacement  or  separation  of  ar- 
ticular surfaces  :  the  term  implies  that  the  soft  parts  have 
been  extensively  lacerated,  including  nerves  and  blood  ves- 
or  that  a  fracture  has  been  produced  in  couneetion  with  the 
dislocation. 

A  partial  luxation  is  one  in  which  the  articular  surfaces  are 
not  wholly  removed  from  one  another,  though  the  function 
of  motion  in  the  joint  is  temporarily  arrested  by  the  displace- 
ment. In  such  dislocations  the  ligamentous  surroundings  are 
not  necessarily  torn,  the  fibrous  structures  being  sufficiently 
elastic  to  admit  of  the  disjunction.  The  injury  is  somewhat 
rare ;  probably  such  displacements  are  occasionally  reduced 
without  the  medical  attendant  fully  understanding  whether 
the  luxation  was  incomplete  or  not. 

In  a  complete  dislocation  the  displaced  bone  is  forced  entirely 
clear  of  the  other  so  far  as  corresponding  articular  surfaces 
are  concerned,  and  finds  lodgment  in  a  new  position,  geneiv 
ally  near  the  old  situation,  as  when  the  head  of  the  luxated 
femur  rests  against  the  border  of  the  acetabulum.  In  a  com- 
plete dislocation  the  capsular  ligament  is  necessarily  torn,  and 
the  head  of  the  luxated  bone  escapes  through  the  rent. 

A  recent  dislocation  is  one  that  has  not  existed  many  weeks; 
in  fact,  a  luxation  of  some  joints  is  old  at  the  end  of  a  week, 
for  it  is  not  time  alone  that  renders  a  dislocation  old  in  a  sur- 
gical sense.  If  such  changes  have  taken  place  in  the  struc- 
tures about  the  joint  as  to  render  reduction  unsafe  or  imprac- 
ticable, the  dislocation  is  practically  old  though  it  have  ex- 
isted only  a  few  days.  A  dislocation,  then,  may  be  considered 
recent,  if  it  can  be  reduced  without  danger  of  rupturing  im- 


DISLOCATIONS. 

portant  nerves,  blood-vessels,  ami  other  structures  which  have 
become  changed  in  their  conditions  by  inflammatory  action, 
or  rendered  unfit  to  assume  their  normal  relations. 

An  old  or  arn-nni  dislocation  is  one  in  which  such  changes 
have  taken  place  in  and  about  the  joint  as  to  render  attempts 
at  reduction  unsafe  and  uncertain.  It  is  not  uncommon  to 
meet  with  luxations  which  have  escaped  detection  or  p; 
unreduced  for  several  weeks  or  even  months;  and  the  ques- 
tion arises  whether  an  attempt  to  overcome  the  displacement 
is  justifiable.  The  humerus  has  been  replaced  after  being  out 
six  months  and  more,  but  to  reduce  a  luxated  elbow  tbat  had 
been  out  six  weeks,  would  be  to  inflict  an  amount  of  injury 
that,  might  result  in  death.  Since  the  introduction  of  chloro- 
form into  surgical  practice,  well  directed  attempts  at  reduction 
of  ancient  dislocations  have  not  been  attended  with  those 
serious  injuries  that  were  wont  to  occur,  and  the  efforts  have 
been  rewarded  with  far  more  successful  results.  T3y  the  man- 
ipulating plan  the  displaced  bone  is  not  so  liable  to  be  frac- 
tured, nor  is  the  danger  of  rupturing  blood  vessels  so  great, 
as  when,  no  anaesthetic  was  used,  and  pulleys  and  other  in- 
struments for  multiplying  force  were  generally  employed. 

A  dislocated  bone  generally  remains  in  the  place  it  origin- 
ally took  when  luxation  occurred;  it  may  then  be  called  a 
/n-'/iii/lce  dislocation,  as  distinguished  from  a  luxation  in  which 
the  displaced  bone  is  made  to  abandon  its  original  position 
and  take  up  with  another,  which  is  called  a  consecutive  disloca- 
tion. For  instance,  a  man  may  have  a  dislocation  of  the 
shoulder,  the  head  of  the  humerus  being  forced  beneath  the 
coracoid  process ;  and  in  going  home  or  in  being  removed 
from  one  place  to  another,  the  bone  may  get  forced  inside 
the  process  and  be  drawn  up  against  the  clavicle:  the  former 
AVOII Id  be  a  primitive,  and  the  latter  might  be  considered  a 
-consecutive  dislocation. 

Joints  which  admit  the  most  extensive  range  of  motion,  as 
the  ball  and  socket, — the  shoulder  and  the  hip — are  the  most 
frequently  dislocated ;  the  ginglymoid,  as  the  knee  and  elbow 
— being  more  restricted  in  their  motions,  rarely  get  displaced. 
According  to  the  tables  of  Malgaigne,  the  shoulder  is  dislo- 
cated oftener  than  all  tne  other  joints  in  the  body.  The  hip 
has  a  deeper  socket,  and  is  not  so  much  exposed  to  displacing 
forces  as  the  shoulder.  The  vertebra1  are  «>  h'rmlv  bound  in 


266  Dl.SI-i 

place  by  ligaments,  and  prevented  from  displacement  bv  com- 
plicated processes,  that  they  seldom  sutler  luxation. 

There  are  few. physicians  of  ten  years'  experience  but  have 
met  with  dislocation  of  the  shoulder  ;  yet  they  may  not  have 
seen  a  luxation  of  any  other  joint.  I  once  asked  an  old  sur- 
geon of  extensive  experience  to  give  me  a  list  of  the  disloca- 
tions he  had  been  called  upon  to  treat ;  and  this  is  his  report : 
Dislocation  of  the  inferior  maxillary,  2;  of  the  cervical  verlc- 
brre,  1 ;  of  the  clavicle,  2  ;  of  the  humerus,  11  ;  of  the  radius, 
3;  of  the  thumb,  3;  of  the  fingers,  2;  of  the  femur.  '2  :  of 
the  patella,  2  ;  of  the  tibio-tarsal  articulation,  complicated 
with  fracture  of  the  fibula,  5  ;  of  the  toes,  3.  It  will  be  seen 
that  in  his  practice  the  shoulder  was  found  dislocated  far  more 
frequently  than  any  other  joint,  though  the  number  is  less 
than  all  the  other  luxations  counted  together.  He  had  never 
seen  a  dislocation  of  both  bones  of  the  arm  at  the  elbow, 
although  it  is  not  an  extreme!}'  uncommon  accident;  and  had 
never  met  with  a  complete  dislocation  of  the  knee,  though  In- 
said  he  had  found  the  joint  in  a  painful  and  rigid  state  which 
he  diagnosed  as  displacement  of  the  semiluuar'cartilages. 

Age  has  an  influence  upon  the  relative  frequency  of  disloca- 
tions ;  the  very  young  and  the  very  old  are  not  liable  to  such 
accidents;  in  middle  life  luxations  most  frequently  occur. 
The  elastic  condition  of  the  tissues  in  youth,  serves  to  decom- 
pose forces  tending  to  produce  luxations,  the  pliant  structure- 
yielding  sufficiently  to  avert  the  accident;  in  advanced  age 
the  bones  become  brittle,  therefore  they  are  more  liable  to  In- 
fractured  than  to  be  dislocated.  Thus,  if  an  individual  sev- 
enty years  old  sustains  a  severe  injury  at  the  hip,  a  dislocation 
could  scarcely  be  expected,  yet  a  fracture  of  the  neck  of  tin- 
femur  would  be  highly  probable.  Elderly  persons  who  sutler 
severe  injuries  of  the  shoulder, -are  most  likely  to  sustain  frac- 
tures of  the  clavicle,  though  dislocation  of  the  humerus  has 
been  met  in  persons  advanced  in  life. 

The  causes  of  dislocation  are  sometimes  quite,  insignificant, 
or  apparently  so.  A  girl  of  sixteen  dislocated  the  shoulder 
in  attempting  to  throw  the  loop  of  a  string  over  a  peg  a  little 
higher  than  >he.  could  icach  ;  another  school  girl  dislocated 
the  head  of  the  radius  while  she  and  a  companion  were  play- 
fully swinging  arms  ;  the  thumb  has  been  luxated  from  seem- 
ingly trivial  causes:  the  under  jaw  i>  frequently  dislocated 


DISLOCATIONS.  267 

while  gaping;  the  patella  maybe  displaced  outwards  when 

the  patient  had  no  reason  to  suspect  even  a  mild  form  of  in- 
jury. Muscular  action  in  such  instances  seems  to  be  adequate 
to  produce  luxation.  If  a  bone  has  been  dislocated  once  it  is 
ever  after  liable  to  the  same  accident :  at  least,  it  is  not  un- 
common for  some  joints  to  suffer  dislocation  a  number  of 
times. 

External  violence  may  operate  directly  and  indirectly  in  pro- 
ducing luxations ;  thus,  a  severe  blow  upon  the  top  of  the 
shoulder  may  drive  the  head  of  the  humerus  downwards  into 
the  axilla  ;  but  if  the  hip  be  dislocated  by  a  force  received  on 
the  knee,  the  action  is  indirect.  There  are  not  many  joints 
that  can  be  dislocated  by  direct  violence;  the  shoulder  is  one, 
and  I  have  known  the  patella  to  be  knocked  out  of  place  by 
a  blow.  A  combination  of  forces  most  frequently  produces  a 
dislocation.  For  instance,  the  elbow  is  forced  upwards  until 
the  humerus  as  a  lever  acts  across  the  acromion  as  a  fulcrum, 
to  lacerate  the  capsular  ligament ;  at  this  point  in  the  progress 
of  the  injury  the  muscles  jerk  the  head  of  the  bone  out  of  its 
normal  relations  with  the  joint.  A  drunken  man  whose  mus- 
cles are  in  a  state  of  relaxation,  rarely  sustains  a  dislocation 
though  exposed  to  the  action  of  forces  that  favor  such  inju- 
ries. In  order  to  produce  a  luxation  of  the  shoulder  in  a 
cadaver,  the  operator  must  first  rupture  the  capsule  of  the 
joint  by  using  the  arm  as  a  lever,  then  push  the  bone  through 
the  rent.  Dead  muscles  will  not  complete  the  injury  after  the 
capsule  has  been  lacerated  and  the  bone  is  presented  in  a  fav- 
orable attitude  for  displacement.  When  a  bone  is  dislocated 
in  life  the  limb  is  generally  in  such  a  position  at  the  time  of 
the  accident  that  the  antagonism  of  the  muscles  is  for  the 
moment  destroyed, — one  set  being  relaxed  and  another,  whose 
action  is  in  an  opposite  direction,  put  violently  upon  the 
stretch . 

Symptoms. — Timothy  Holmes,  in  "his  System  of  Surgery,  says  : 
"  A  complete  dislocation  is,  in  typical  cases,  attended  with 
sii'-li  very  distinct  symptoms,  that  when  these  are  fairly  de- 
tailed upon  paper  the  reader  is  tempted  to  say  that  the  injury 
is  unmistakable.  Yet  the  great  number  of  old  unreduced 
dislocations  which  are  still  seen,  even  in  patients  who  have 
been  from  the  first  under  medical  supervision,  proves  that, 
notwithstanding  the  elaborate  care  with  which  the  symptoms 


268  DISLOCATIONS. 

of  dislocation  in  general,  and  of  each  special  injury  in  partic- 
ular, have  been  described  ever  since  the  time  of  Astley  Cooper, 
such  mistakes  can  not  always  be  avoided,  even  by  well-in- 
formed and  careful  men  ;  and  it  is  no  doubt  true  that  errors 
in  diagnosis  on  this  head  will  sometimes  occur  to  the  best 
surgeons,  in  consequence  of  extreme  depth  of  the  parts,  of 
great  effusion  and  swelling  over  them,  or  of  complication  with 
other  injuries;  but  with  proper  care  such  mistakes  ought  to 
be  very  seldom  made  even  at  the  time  of  the  accident,  and 
attention  to  the  subsequent  progress  of  the  case  will  always 
enable  the  surgeon  to  correct  his  error  while  there  is  yet  a  fair 
prospect  of  easy  reduction."  I  take  pleasure  in  being  able  to 
otter  such  distinguished  testimony  in  favor  of  opinions  so  near 
in  conformity  with  my  own.  In  the  malpractice  suit  of 
"  Larkin  versus  Jones,"  tried  at  Marion,  Grant  Co.,  Ind.,  in 
April,  1869,  1  declared  to  the  court  that  it  was  no  rare  or  un- 
common occurrence  for  physicians  of  average  professional 
qualifications  and  experience,  and  of  considerable  snrgi'-al 
pretensions,  to  fail  to  discover  dislocations,  even  when  culled 
early,  and  having  opportunity  to  examine  the  case  before 
swelling  and  other  conditions  tending  to  mask  the  real  state 
of  the  injury,  had  come  on.  I  cited  cases  of  dislocation  of 
the  shoulder  which  had  passed  undetected  through  the  hands 
of  quite  pretentious  surgeons.  This  opinion  was  attacked  as 
unsound,  by  Dr.  Win.  Lomax,  and  other  physicians  of  Grant 
County,  who  thought  a  dislocation  of  the  shoulder  would 
never  be  overlooked  by  a  physician  of  ordinary  skill  and 
ability,  though  the  injury  be  of  two  days'  standing  when  tirst 
observed.  All  claimed  to  have  had  several  cases  of  disloca- 
tion of  the  shoulder  to  treat,  and  denied  ever  having  been  in 
doubt  in  regard  to  the  nature  of  the  injury. 

The  general  symptoms  of  dislocation  are,  great  pain  sud- 
denly following  the  accident,  loss  of  motion  and  rigidity  in 
the  articulation,  change  in  the  natural  contour  of  the  joint, 
shortening  of  the  limb  in  most  instances,  loss  of  voluntary 
motion  except  to  a  limited  extent  and  in  certain  directions, 
absence  of  crepitus,  a  disposition  to  remain  in  place  after  the 
luxated  bone  is  reduced.  Fractures  have  quire  different 
symptoms;  they  are  attended  with  pain  and  deformity,  as  are 
dislocations,  but  there  is  an  increase  of  mobility,  the  existence 
of  crepitus,  the  pain  is  not  overcome  by  reduction,  and  the 


DISLOCATIONS.  269 

displaced  bone  will  not  stay  in  place  when  adjusted.  There 
are  two  distinct  injuries,  a  fracture  and  a  dislocation,  of  the 
shoulder,  which  closely  resemble  each  other;  a  luxation  of 
the  humerus  inwards  appears  much  like  a  fracture  of  the 
neck  of  the  scapula.  The  fracture  allows  of  free  passive  mo- 
tion, and  crepitus  can  generally  be  produced  after  reduction ; 
and  when  adjusted  and  left  to  itself  the  displacement  readily 
occurs.  In  dislocation  the  arm  is  rigid,  and  will  not  admit  of 
passive  motion,  and  reduction  having  been  effected  the  dis- 
placed bone  will  remain  in  its  natural  position  without  assist- 
ance, no  crepitus  can  be  elicited,  and  the  coracoid  and  acro- 
mion  processes  maintain  the  same  distance  between  each 
other. 

Fractures  of  the  neck  of  the  femur  are  characterized  by  in- 
creased mobility  and  ei-<r»i»n  of  the  foot;  dislocation  of  the 
lemur  is  attended  with  great  rigidity  and  inversion  of  the  foot. 

Injuries  about  the  other  joints  exhibit  certain  signs  which 
indicate  whether  a  fracture  or  a  dislocation  exists  ;  and  when 
luxated  the  natural  axis  of  the  bone  is  so  changed  that  it  no 
longer  corresponds  with  its  socket,  there  is  intense  pain  where 
the  head  of  the  bone  rests  in  its  new  situation,  and  the  limb 
is  greatly  benumbed  as  well  as  rigid. 

If  the  symptoms  be  not  sufficiently  distinctive  to  remove 
all  doubts  in  regard  to  the  nature  of  the  accident,  the  patient 
may  be  put  under  the  influence  of  anaesthesia,  and  then  care- 
fully examined. 

PATHOLOGICAL  ANATOMY. — In  a  recent  dislocation  it  is  found 
that  the  capsular  ligament  is  torn,  and  more  or  less  injury  may 
be  done  to  the  adjacent  tissues;  muscles  are  sometimes 
severed  from  their  attachments,  ruptured,  or  stretched,  accord- 
ing to  the  nature  and  extent  of  the  displacement.  The  great 
nerves  in  the  vicinity  of  the  joint,  (such  as  the  circumflex  be- 
hind the  shoulder)  are  often  compressed  or  lacerated  ;  hence 
severe  pain  at  the  time  of  the  accident,  and  a  succeeding 
paralysis  of  the  parts  supplied  with  these  nerves,  which 
is  sometimes  irremediable.  Blood  vessels  may  be  pressed  upon 
so  as  to  obstruct  the  circulation  in  the  limb.  Dr.  Goldsmith, 
of  Louisville,  reports  a  case  of  dislocation  of  the  femur  on  to 
the  brim  of  the  pelvis  so  as  to  lie  under  the  femoral  artery. 
Remaining  unreduced,  in  two  months  it  produced  a  diffused 
aneurism  of  that  vessel. 


270  DISLOCATIONS. 

It  is  rare  to  find  a  simple  dislocation  of  the  ankle,  for  frac- 
ture of  the  fibula  is  almost  a  sure  complication  ;  and  a  back- 
ward luxation  of  the  ulna  is  liable  to  be  complicated  with 
fracture  of  the  coronoid  process. 

If  the  bones  be  restored  to  their  natural  position,  all  of 
these  defects  and  lesions  are  soon  repaired.  The  ruptured 
capsule  heals,  the  stretched  and  lacerated  muscles,  tendons. 
and  fibrous  tissues  regain,  in  a  great  measure,  if  not  entirely, 
their  former  condition,  and  even  the  nerves  which  may  have 
been  contused  or  lacerated,  may  at  length  recover  their  won  ted 
functions.  To  ensure  perfect  restoration  it  is  necessary  that 
the  bone  be  not  allowed  to  escape  from  its  normal  position 
while  the  recovery  is  made  ;  a  repetition  of  the  luxation  might 
prevent  the  healing  of  the  rent  in  the  cap-ule,  and  the  return 
of  strength  to  the  disabled  parts. 

If,  on  the  contrary,  the  dislocation  remain  unreduced,  other 
changes, besides  those  which  immediately  attend  the  aeeident. 
necessarily  follow.  These  arise  from  prolonged  irritation  and 
inflammatory  action,  as  well  as  from  efforts  to  establish  a  sub- 
stitute for  the  old  joint.  The  head  of  the  dislocated  bone 
forms  for  itself  a  cavity  or  new  socket  in  the  bone  upon  which 
it  is  thrown, — a  cavity  which  is  produced  in  part  by  absorp- 
tion under  pressure,  and  in  part  by  deposits  of  osseous  mate- 
rial around  the  forming  socket.  The  new  articular  cavity  has 
furnished  to  it  something  akin  to  synovia!  tissue,  and  the  old 
socket  becomes  filled  with  fibroid  structures.  The  ginglymoid 
articulations  do  not  make  so  much  progress  towards  establish- 
ing new  joints  as  the  ball  and  socket  variety.  In  many  in- 
stances complete  anchylosis  takes  place, — a  condition  which  is 
not  uncommon  in  unreduced  dislocations  of  the  small  joints. 

The  muscles  and  tendons  directly  influenced  by  a  dislocated 
bone  become  materially  and  functionally  altered ;  in  some 
ancient  dislocations,  the  relaxed  muscles  may  be  shortened  or 
retracted  to  an  extent  that  can  never  be  overcome  ;  the  ten- 
dons get  torn  from  their  attachments  and  forced  from  their 
positions  (as  is  often  the  case  with  the  long  tendon  of  the 
biceps)  ;  and  from  inflammatory  action  the  various  tissues  may 
become  blended  in  a  mass,  so  that  an  attempt  to  break  up 
these  adhesions  would  be  attended  with  laceration.  Adventi- 
tious bony  material  has  been  found  in  these  blended  masse-, 
as  if  the  conservative  vital  forces  were  en  paired  in  furnishing 


DISLOCATIONS.  271 

osseous  matter  to  repair  a  fracture  or  to  construct  a  new  ar- 
ticulation. 

The  head  of  the  radius  thrown  upon  the  anterior  or  poste- 
rior aspect  of  the  humerus,  may  unite  by  osseous  or  fibrous 
material  so  as  to  prevent  rotation.,  as  well  as  impede  flexion 
.and  extension  of  the  forearm.  The  backward  dislocation  of 
the  ulna,  if  left  unreduced,  would  be  followed  by  such  changes 
of  various  kinds,  articular,  ligamentous,  and  muscular,  as  to 
result  in  permanent  deformity  in  a  few  weeks. 

Evidence  is  furnished  by  dissection  that  in  rare  cases  tin- 
rent  in  the  capsular  ligament  so  far  unites  in  a  few  days  that 
the  hole  which  admitted  the  passage  of  the  bone  out  of  the 
joint,  will  no  longer  permit  it  to  go  back  again.  Hilton,  in 
Guy's  Hospital  Reports,  relates  a  case  dissected  three  weeks 
after  the  accident,  in  which  the  rent  in  the  capsule  had  so  far 
healed  as  to  prevent  a  return  of  the  head  of  the  bone.  The 
femur,  when  left  unreduced  upon  the  dorsum  ilii  for  two  or 
three  months,  is  prevented  from  returning  to  the  acetabulum 
by  a  narrowing  of  the  rent  through  which  it  escaped  from  the 
joint;  but  if  well  directed  means  be  employed  to  reduce  the 
bone  to  its  proper  position,  the  repaired  ligament  will  so  far 
yield  as  to  allow  the  head  of  the  femur  to  go  back  into  place. 

Structures  thrown  into  disuse  on  account  of  the  dislocation, 
undergo  gradual  atrophy ;  and  any  part  of  the  organism, 
whether  vessel,  nerve,  or  bone,  that  is  pressed  upon,  suffers 
marked  alterations,  if  not  entire  obliteration. 

When  firm  adhesion  takes  place  between  a  large  artery  or 
vein  and  the  dislocated  bone,  there  is  great  risk  of  serious  or 
even  fatal  consequences  from  laceration  of  such  vessels  during 
attempts  at  reduction.  In  Eve's  "  Collection  of  Surgical 
Cases  "  are  a  few  reports  of  serious  injuries  following  attempts 
at  the  reduction  of  luxations.  They  are  all  translations  from 
French  journals.  "  In  one  of  them  the  attempts  to  reduce  the 
dislocated  joint  produced  a  rupture  of  the  axillary  artery, 
gangrene,  and  subsequently,  the  death  of  the  patient. 

"  In  another,  hemiplegia  ensued,  most  likely  in  consequence 
of  extravasation  in  the  brain,  from  efforts  used  in  the  reduc- 
tion ;  the  paralysis  gradually  diminished,  but  the  lower  ex- 
tremity never  recovered  its  natural  heat  and  sensibility,  and 
the  use  of  the  arm  was  almost  completely  lost. 


272  DISLOCATION.-5. 

"  Iii  a  third  case  the  dislocated  shoulder  was  reduced  thirty- 
eight  days  after  the  accident;  immediately  after  the  operation, 
emphysema  supervened  over  the  arm  and  a  great  part  of  the 
back;  very  soon  afterwards  violent  headache  and  hemiplegia 
ensued,  and  proved  fatal  on  the  twelfth  day.  On  examination, 
the  hvachial  plexus  was  found  extensively  lacerated ;  at  the 
sixth,  seventh,  and  eighth  cervical  and  the  first  dorsal  verte- 
brae, the  spinal  cord  was  swollen,  softened,  and  of  a  reddish- 
brown  color. 

"  In  the  fourth  case,  the  reduction  \vas  followed  by  an  enor- 
mous painful  swelling  of  the  extremity,  the  arm  could  never 
be  used,  and  the  fingers  only  retained  a  very  small  degree  of 
sensibility  .and  motion. 

"  Ii\  a  case  of  dislocated  hip,  the  reduction  was  made  very 
soon  after  the  accident,  and  the  head  of  the  femur  was  very 
distinctly  heard  to  slip  into  the  cotyloid  cavity  ;  the  patient 
died,  however,  five  days  after  the  operation.  The  anterior 
and  exterior  part  of  the  hip  was  found  ecchymosed ;  the 
pyriformis,  gemelli,  and  quadratus  femoris,  the  capsule  and 
ligamentum  teres  were  ruptured,  and  the  cavity  of  the  joint 
was  filled  wTith  pus.  In  this  case,  the  fatal  termination  was 
apparently  rather  the  result  of  the  dislocation,  than  of  the  re- 
duction ;  the  observations,  however,  of  M.  Faubert,  show  how 
cautiously  the  attempts  at  reduction  ought  to  be  made,  and 
how  necessary  it  is  to  consider  whether  a  sufficient  extending 
force  can  be  used,  without  inflicting  serious  injury  on  the 
patient." 

It  will  be  observed  that  extending  force  was  relied  on  in 
these  unfortunate  attempts  at  reduction;  and  it  is  not  even 
suggested  that  there  may  be  an  easier  and  safer  way  of  re- 
ducing dislocations.  I  have  known  thehumernsto  be  broken 
in  a  fruitless  attempt  to  reduce  an  ancient  dislocation  with  in- 
struments for  multiplying  force.  Such  an  instance  occurred 
in  this  city  a  few  years  ago,  but  the  surgeon  did  not  see  fit  to 
report  the  case  that  the  profession  at  large  might  be  benefited 
by  the  lesson  it  conveyed. 

Another  unfortunate  attempt  to  reduce  an  ancient  disloca- 
tion of  the  shoulder  (if  the  diagnosis  was  correct)  was  made 
in  this  city  some  years  ago,  and  the  surgeon  (Dr.  George  ( •. 
Blackman)  published  an  account  of  the  case.  The  "  Western 
Lancet  "  for  November,  1856,  contains  the  doctor's  version  of 


DISLOCATIONS.  273 

the  nature  of  the  injury,  the  operation  to  effect  reduction,  and 
the  result.  In  a  letter  to  the  editor  of  that  journal,  he  says: 
"  About  the  10th  ult.,  aided  by  yourself,  1  succeeded  in  re- 
ducing by  manipulation,  without  the  pulleys,  a  dislocation 
into  the  axilla,  of  eighty  days'  standing.  The  reduction  was 
accomplished  in  a  very  few  minutes,  under  the  influence  of 
chloroform  and  ether,  and  the  next  morning  the  patient  left 
for  the  country,  in  a  comfortable  condition.  Since  that.  I  have 
received  no  tidings  from  him.  Encouraged  by  the  result  in 
this  case,  another  patient,  himself  a  physician,  a  tall,  athletic 
man,  and  about  fifty  years  of  age,  decided  to  submit  to  the 
.same  manipulation,  although  his  arm  had  been  dislocated  for 
about  sixteen  weeks.  The  dislocation  was  downwards  and 
inwards,  and  about  the  tenth  week  an  unsuccessful  attempt, 
by  another  surgeon,  had  been  made  with  the  pulleys,  to  which 
the  force  of  six  men  was  applied  for  two  and  a  half  hours. 
The  patient  being  under  the  influence  of  chloroform  and  ether, 
aided  by  yourself,  Drs.  Fries,  Cary,  Graham  and  Kauft'man,  I 
commenced  my  manipulations,  adducting,  rotating,  abduct- 
ing, and  elevating  the  arm.  These  efforts  had  been  made  for 
about  ten  minutes,  and  the  least  possible  violence  employed, 
when  a  tumefaction  appeared  in  the  pectoral  region,  which  in 
a  few  minutes  attained  a  considerable  size.  Supposing  that 
the  axillary  artery  was  ruptured,  as  no  pulse  could  be  felt  at 
the  wrist,  a  ligature  was  immediately  applied  to  the  vessel  at 
the  upper  part  of  its  course.  The  operation  was  performed 
about  10  o'clock  A.  M.,  and  compression  of  the  pectoral  region 
made  by  means  of  a  sponge  and  broad  roller.  On  removing 
this  the  next  morning,  the  tumefaction  had  nearly  disappeared. 
The  patient  continued  comfortable,  and  about  nine  days  after 
the  application  of  the  ligature,  I  was  compelled  to  leave  the 
city  on  a  professional  visit  to  Indiana.  I  left  on  Friday  after- 
noon and  returned  on  Monday  morning,  at  which  time  I 
learned  that  my  patient  had  died  on  Sunday  morning,  from 
hemorrhage  at  the  seat  of  ligature.  Two  physicians,  his  most 
intimate  friends,  lodged  in  the  same  house  with  him,  but  be- 
fore they  reached  his  bedside  the  quantity  of  blood  lost  was 
so  great  that  he  sank  exhausted  in  about  two  hours  from  the 
first  and  only  attack  of  hemorrhage.  Previous  to  my  de- 
parture for  Indiana,  I  had  suggested  to  the  physicians  in 
charge,  the  importance  of  having  compressed  sponge  at  hand, 
18 


274  DISLOCATIONS. 

to  be  used  in  any  emergency  of  the  kind,  but  tliis  was  not 
used  by  the  attendant;  instead  of  applying-  pressure  instanta- 
neously, he  went  in  search  of  the  physicians,  who,  at  that 
early  hour  in  the  morning  were  in  bed.  The  time  thus  lost 
unquestionably  led  to  the  fatal  catastrophe. 

"  I  might  refer  you  to  numerous  instances  of  success  in  the 
reduction  of  old  dislocations — from  two  to  six  months'  stand- 
ing— which  have  occurred  since  the  days  of  Wiseman,  but  I 
propose  to  notice  only  the  accidents  by  which  some  of  these 
attempts  have  occasionally  been  followed.  One  of  the  earliest 
recorded,  so  far  as  we  have  been  able  to  learn,  is  the  case  re- 
ported by  Desault 

"  During  the  effort  of  this  surgeon  to  reduce  an  old  disloca- 
tion, suddenly  a  considerable  '  tumeur  aerieime  '  appeared  below 
the  clavicle,  which  Desault  attributed  to  the  '  ilefjnyeniettt  <lc 
V air  amasse  entreles  cellules  rompues  du  tissu  <-clinl<iir< •! '  In  a 
few  days  this  tumor  entirely  subsided  under  the  influence  of 
1  astringents  et  une  compression  methodique.'  Whether  it  was  the 
result  of  a  disengagement  of  air  from  the  lacerated  cells  of 
the  cellular  membrane,  as  supposed  by  Desault,  or  uf  a  rup- 
ture of  blood  vessels,  we  leave  the  reader  to  determine. 

"It  is  somewhat  singular  that  Desault  should  have  met 
with  two  cases  of  this  extraordinary  phenomenon.  Pellatan's 
explanation,  in  our  opinion,  throws  some  light  on  this  subject. 
In  an  attempt  to  reduce  a  luxation  of  four  months'  standing, 
the  same  kind  of  *  tumeur  aerienne '  appeared.  It  was  opened, 
and  the  hemorrhage  from  the  torn  artery  was  fatal. 

"  Malgaigne  states  that  he  is  acquainted  with  but  a  single 
instance  of  an  '  emphyseme  veritable'  following  a  reduction, 
and  that  is  the  one  reported  by  Flaubert.  The  patient,  a 
female  set.  70,  screamed  violently  during  the  operation,  and 
Malgaigue  is  disposed  to  believe  that  the  emphysema  was  in- 
dependent of  the  luxation,  or  the  reduction. 

"Malgaigne,  himself,  attempted  reduction  in  a  case  of 
sixty-eight  days'  standing,  but  was  forced  to  discontinue  his 
efforts  in  consequence  of  the  sudden  appearance  of  a  tume- 
faction in  the  axilla,  and  on  1  lie  shoulder.  Ice  was  applied, 
and  in  the  course  of  a  few  hours  the  swelling  was  arrested, 
and  by  the  twenty-second  day,  the  blood  which  he  thinks 
came  from  ruptured  muscular  branches,  was  completely  ab- 
sorbed. 


DISLOCATIONS.  275 

"  A  case  occurred  to  Flaubert,  in  which,  besides  the  tume- 
faction, the  pulse  could  not  be  felt  at  the  wrist.  The  hand 
was  cold,  insensible,  and  immovable.  The  next  day,  however, 
the  pulse  returned  to  the  wrist,  and  in  the  course  of  twenty- 
six  days  the  effused  blood  was  absorbed.  Froriep  lost  a 
patient  from  a  rupture  of  the  axillary  vein,  which  proved 
fatal  in  an  hour  and  a  half  after  the  operation.  The  reader 
may  find  in  the  comprehensive  treatise  of  Malgaigne,  details 
of  cases  in  which  the  axillary  artery  was  ruptured.  We  pass 
-over  those  observed  by  Yerdnc,  Petit,  Plainer,  Delpech,  and 
that  referred  to  by  Sir  Charles  Bell,  in  his  Operative  Surgery 
The  late  Dr.  John  C.  Warren  tied  the  subclavian  to  arrest  the 
progress  of  an  enormous  atieurismal  tumor  in  the  axilla,  the 
result  of  the  reduction  of  a  recent  dislocation,  and  of  sup- 
posed pressure  of  the  operator's  boot.  In  this  instance  the 
coats  of  the  artery  were  so  contused  that  sloughing  took 
place  during  a  fit  of  coughing,  five  days  after  the  accident. 
In  1824,  M.  Leudet  lost  a  patient  at  the  hospital  at  Rouen. 
The  dislocation  was  only  of  eleven  days'  standing,  and  was 
complicated  with  a  fracture  of  the  margin  of  the  glenoid 
cavity,  as  in  the  two  fatal  cases  which  occurred  in  the  practice 
of  Prof.  Gibson,  of  Philadelphia.  The  latter  cases  are  too 
familiar  to  every  surgical  student  to  require  particular  men- 
tion in  this  place.  Prof.  Gibson,  in  connection  with  the  re- 
port of  the  above  cases,  gives  briefly  the  details  of  a  fatal 
operation  by  David,  of  Kouen.  The  luxation  had  existed 
several  months,  and  great  force  was  employed  in  the  reduc- 
tion. This  resulted  in  an  inflammation,  mortification,  and 
death.  Some  years  since,  Lisfranc  attempted  the  reduction  in 
a  case  of  four  months'  standing.  He  succeeded  ;  but  on  vis- 
iting the  patient  an  hour  afterwards  he  was  found  dead.  His 
death  was  attributed  to  cerebral  congestion,  as  the  autopsy 
showed  the  axillary  artery,  veins,  and  nerves  uninjured.  In 
the  same  volume,  MM.  Lenoir  and  Larrey  refer  to  cases  in 
which  they  have  met  with  lesion  of  the  brachial  plexus,  giv- 
ing rise  to  paralysis,  and  yet  these  were  recent  cases,  and  the 
reduction  was  most  readily  accomplished.  But  I  will  not 
multiply  cases  of  this  kind  ;  those  already  related  will  suifice, 
in  the  minds  of  many,  to  answer  the  question — At  what 
period  of  time  after  a  dislocation  of  the  shoulder,  is  an  attempt 
at  reduction  justifiable  ?  When  Prof.  Gibson  lost  his  first 


276  DISLOCATIONS. 

patient,  lie  wrote  that  'should  a  case  similar  in  external  ap- 
pearance to  that  of  James  Schofield  again  occur,  I  shall  feel 
justified  in  adopting  a  similar  course.'  When  he  had  lost  his 
second  patient,  (John  Langton),  he  expressed  his  views  as 
follows  :  "  The  conclusions  which  I  am  now  prepared  to  draw 
are  directly  the  reverse  of  what  I  have  stated  in  some  of  the 
foregoing  pages ;  I  am  now  disposed  to  condemn,  in  the  most 
unqualified  terms,  all  attempts  at  the  restoration  of  ancient 
luxations  of  the  humerus  and  other  hones — except  in  cases 
where  the  patient  is  remarkably  thin  and  debilitated,  and 
where  there  has  been  little  or  no  inflammation  at  the  time  of, 
or  subsequent  to  the  displacement.'  At  a  meeting  of  the  So- 
ciete  de  Chiruryie  of  Paris,  July  3,  1850,  M.  Maisonneuve  re- 
ported a  case  in  which,  after  M.  Yelpeau  had  failed,  he  suc- 
ceeded in  reducing  a  luxation  of  the  shoulder  of  twelve  week>' 
standing,  and  elated  with  this  triumph  over  the  veteran  of  La 
Charite,  he  asserts  there  are  but  few  cases  in  which,  with  the 
aid  of  chloroform,  we  may  not  succeed.  '  Quclles  resistance  </ 
a-t-il  a  vaincre  id,  en  effd  ? '  he  asks.  '  II  n'y  a  presque  pas 
d'engrenaye;  les  muscles  sont  neutralises  par  le  chloroform e ;  il  n*>. 
reste  done  que  des  adherences  jibreuses  :  Con  pourra  presque  touj<»  .  .«•• 
les  surmonter,  ou  les  rompre.'  But  these  fibrous  adhesions  arv. 
not  the  only  obstacles  to  overcome ;  where  the  tissues  sur- 
rounding the  head  have  become  consolidated  by  inflammation, 
the  axillary  vessels  and  nerves  must  be  in  danger  of  lacera- 
tion. Perhaps,  however,  as  M.  Maisonneuve  suggests,  this 
accident  may  be  avoided  by  'extensions  preparatoires,'  as  in  the 
attempts  to  restore  contracted  limbs  to  their  natural  shape." 
Cases  attended  with  success  are  frequently  reported,  after 
the  dislocation  has  existed  from  six  weeks  to  as  many  months. 
Attempts  attended  with  failures  must  be  quite  common,  but 
accounts  of  them  rarely  get  into  print.  If  all  the  bad  conse- 
quences had  occurred  in  cases  subjected  to  the  action  of  pul- 
leys and  Jarvis'  Adjuster,  the  blame  might  be  mostly  charged 
to  those  powerfully  acting  instruments,  but  where  gentle 
manipulation  alone  was  employed  there  have  been  some  un- 
fortunate results.  In  ancient  dislocations  of  the  shoulder,  a 
joint  that  has  been  attended  with  a  large  proportion  of  un- 
fortunate attempts  at  reduction,  the  arm  should  be  subjected 
to  such  movements  as  would  tend  to  detach  the  head  of  the 
humerus  from  any  adventitious  connections  with  the  struc- 


DISLOCATIONS.  277 

tnres  in  the  armpit.  The  surgeon  can  generally  discover 
during  these  preparatory  manipulations  whether  the  adhesions 
are  firm  and  extensive  ;  and  he  -will  be  governed  somewhat 
by  the  evidence-  thus  obtained.  If  the  head  of  the  dislocated 
bone  can  be  rotated  and  moved  freely  in  every  direction  with- 
out seeming  to  disturb  the  blood  vessels  of  the  axilla,  there  is 
very  little  danger  of  doing  mischief  in  moderate  attempts  at 
reduction.  I  have  seen  a  surgeon  use  his  boot  heel  in  the 

o 

axilla  as  a  fulcrum,  and  then  exert  all  his  strength  in  a  violent 
and  excited  manner  to  effect  a  reduction  by  pulling  and  twist- 
ing the  arm  in  all  directions,  without  regard  to  method  or 
reason. 

If  a  vessel  be  ruptured,  which  is  made  known  by  a  quickly 
forming  tumor  in  the  axilla,  and  by  loss  of  pulse  at  the  wrist 
if  the  main  artery  be  torn,  the  grave  question  arises.  What  is 
then  best  to  be  done?  Of  course,  any  additional  efforts  to 
effect  a  reduction  must  be  abandoned;  and  well  directed  mea- 
sures promptly  adopted  to  arrest  the  extravasation  of  blood. 
If  it  be  certain  that  the  axillary  artery  is  ruptured,  compres- 
sion should  be  made  upon  the  subclavian  where  it  crosses  the 
rib  ;  and  the  force  should  not  be  relaxed  for  forty-eight  houis 
or  more.  It  is  possible  that  in  the  course  of  time  the  blood 
already  extravasated  would  form  a  firm  coagulum  and  arrest 
the  hemorrhage.  Well  directed  and  prolonged  compression 
has  resulted  favorably;  and  ligation  of  the  subclavian  and 
axillary  have,  in  the  few  instances  performed,  proved  fatal. 
Certainly  such  want  of  success  attending  deligation,  does  not 
warrant  a  repetition  of  the  operations,  though  we  reason  with 
ourselves  that  there  can  be  no  hope  except  in  the  ligature. 

Generally  a  bone  which  has  been  dislocated,  will  remain  in 
place  when  once  returned  to  its  natural  position,  especially  if 
a  little  care  be  exercised  in  the  use  of  the  limb  for  a  few 
weeks,  or  until  it  is  presumed  that  the  rent  in  the  capsular 
ligament  has  healed,  and  the  different  tissues  involved  in  the 
injury  have  returned  to  their  normal  state  and  relative  condi- 
tions. However,  in  rare  instances,  there  seems  to  be  a  dispo- 
sition for  the  luxation  to  recur  upon  the  most  trivial  oppor- 
tunity. I  once  had  a  patient  whose  shoulder  1  reduced  five 
times,  at  intervening  periods  of  a  few  weeks  ;  and  the  last 
time  I  kept  the  arm  in  a  slin<j;  tor  two  months  as  a  safeguard 
against  a  recurrence  of  the  accident.  I  had  induced  the 


278'  DISLOCATIONS. 

patient  to  keep  the  arm  by  the  side  for  two  weeks,  hut  that 
length  of  time  did  not  prove  sufficient  to  prevent  a  recurring 
luxation.  The  patient  \vas  ;i  \voinan  about  thirty  years  of 
age,  who  received  the  first  dislocation — of  the  right  shoulder 
—in  a  fall  from  a  wagon  ;  within  a  week  she  dislocated  the 
arm  again  while  sweeping,  the  hand  being  raised  at  the  time 
and  the  elbow  projecting  outward  from  the  body  and  upward  ; 
the  third  displacement  occurred  while  fixing  a  window  curtain 
as  high  as  she  could  reach ;  the  fourth  happened  in  the  act  of 
saving  herself  from  a  fall;  and  the  fifth  and  last,  while  hang- 
ing clothes  on  a  line  higher  than  her  head.  All  of  the  acci- 
dents oecurred  within  a  period  of  six  months  ;  and  in  eaeh 
instance  there  was  no  trouble  in  reducing  the  bone  to  place 
by  ordinary  manipulation,  no  chloroform  being  used.  I  began 
to  suspect  that  the  edges  of  the  rent  in  the  capsule  had  become 
covered  with  synovial  membrane,  and  thereby  offered  an  open 
and  smooth  passage-way  for  the  escape  of  the  bone  from  its 
normal  position.  The  suspicion  grew  stronger  from  the  fact 
that  each  succeeding  reduction  was  attended  with  less  and 
less  trouble.  Whether  the  rent  ever  closed  T  am  unable  to 
state;  yet  sufficient  contraction  took  place  in  it  during  the 
long  period  in  which  the  arm  was  bound  to  the  side  by  means 
of  a  sling,  to  be  a  protection  against  another  accident  of  the 
kind.  Dr.  Jay,  of  Marion,  Indiana,  oiiee  had  u  similar  case  to 
manage.  He  reduced  a  recurring  dislocation  of  the  shoulder 
several  times;  and  at  length  the  patient,  upon  having  his 
arm  re-dislocated,  applied  to  another  surgeon  for  relief.  The 
second  surgical  attendant  was  not  on  friendly  relations  with 
the  first,  therefore  he  led  the  patient  to  believe  that  the  dis- 
placed bone  had  never  been  properly  reduced,  and  instigated 
him  to  commence  a  suit  for  the  recovery  of  damages.  The 
plaintiff,  however,  failed  to  get  a  decision  in  his  favor. 

In  the  September  number  (1869)  of  the  Western  Journal  of 
M.tli^iK',  \Y.  II.  Thompson,  M.D.,  of  Vandalia.  < ).,  report-  a 
case  of  recurring  dislocation  of  the  hip,  which  is  not  without 
interest.  u  April  9th,  1869,  I  visited  a  patient  in  conjunction 
with  Dr.  II.  1).  Xunemaker,  for  the  purpose  of  reducing  a 
dislocation  of  the  head  of  the  femur  of  three  days'  standing. 
Our  patient,  a  boy.  aged  sixteen  years,  muscular  and  healthy. 
had  been  playing  with  a  colt,  which  became  unmanageable, 
running  violently  against  him.  dislocating  the  head  of  the 


DISLOCATIONS.  279 

femur  upward  and  backward,  upon  the  dorsum  of  the  ilium. 
The  injured  limb  lay  in  a  semi-flexed  position,  the  heel  ab- 
ducted and  the  toes  inverted,  resting  on  the  instep  of  the 
opposite  foot.  Measurement  revealed  about  an  inch  and  a 
half  of  shortening.  The  patient  was  put  under  the  influence 
of  chloroform,  and  the  dislocation  reduced  by  manipulation, 
(Reid's  method).  The  first  effort  we  made  the  head  glided 
from  its  bed;  the  circular  movement  brought  it  under  the 
acetabulum,  converting  it  into  a  sub-pubic  dislocation.  The 
movement  was  then  reversed,  which  brought  the  head  of  the 
bone  to  its  first  position  on  the  dorsum  ilii.  The  limb  was 
again  brought  across  its  fellow,  and  the  circular  move- 
ment carefully  made,  at  the  same  time  guarding  the  head  of 
the  bone  from  passing  around  the  socket.  To  our  gratifica- 
tion the  head  passed  in  with  an  audible  snap,  the  limb  assum- 
ing its  normal  position.  The  patient  was  then  placed  in  the 
horizontal  attitude,  and  the  injured  limb  secured  to  its  fellow 
by  means  of  a  roller  extending  from  the  ankle  to  the  knee. 
On  the  following  da}T,  on  our  first  visit,  the  hip-joint  was  found 
to  have  been  dislocated  during  the  night.  The  bo}',  contrary 
to  most  positive  orders,  had  attempted  to  raise  himself  up  in 
bed,  and  at  the  same  time  turning  partially  around,  threw  the 
head  of  the  bone  out ;  the  leg  assuming  the  same  position  as 
when  we  tirst  saw  it.  Again  the  patient  was  placed  under 
the  influence  of  an  anaesthetic,  and  the  luxation  reduced  as  in 
the  first  operation.  He  was  then  secured  firmly  by  means  of 
a  splint  and  bandage  to  the  couch  in  which  he  lay,  in  order 
to  guard  against  a  third  luxation.  In  this  secured  position  he 
lay  for  seven  days,  doing  well,  except  some  slight  peritonitis 
occasioned  by  other  injuries  received  in  conjunction  with  the 
first  dislocation.  During  the  night  following  the  seventh  day, 
he  loosened  the  bandage  which  held  his  head  and  shoulders 
to  the  bed.  Finding  himself  again  free,  his  first  impulse  was 
to  get  up.  (tie  seemed  unable  to  appreciate  his  condition.) 
In. this  attempt  he  again  threw  the  head  of  the  bone  out  of 
the  socket.  This,  in  our  opinion  was  easily  accomplished. 
In  the  first  place,  theiv  was  an  extensive  laceration  of  the 
<.apsular  ligament,  allowing  the  head  to  fflide  easilv  from  the 

o  O  O  *i 

socket;  and  secondly,  the  limb  in  its  secured  position  to  the 
splint  and  bed.  with  the  shoulders  and  body  free  to  move  in 
the  direction  of  the  erect  posture,  and  to  the  right.  These 


280  DISLOCATIONS. 

movements  would,  under  the  circumstances,  certainly  produce 
a  dislocation  (the  left  limb  being  the  injured  one).  At  our 
request,  Dr.  J.  C.  Reeve,  of  Dayton,  Ohio,  was  called  in  coun- 
sel, in  order  to  fortify  ourselves  against  any  subsequent 
trouble,  in  a  legal  point  of  view.  The  patient  was  again 
anaesthetized,  and  Dr.  Beeve  thought,  upon  first  examination, 
there  might  be  fracture  within  the  capsular  ligament ;  but, 
upon  further  investigation,  coincided  with  our  previous  diag- 
nosis. We  then  proceeded  to  reduce  the  luxation  in  the  man- 
ner before  mentioned,  and  with  similar  success.  At  the  doc- 
tor's suggestion,  the  splint  was  reduced  in  width  from  five 
inches  to  three,  and  not  to  be  secured  to  the  bed,  and  the  toe 
was  everted  to  about  seventy-five  degrees — the  foot  abducted 
about  four  inches  from  the  normal  axis  of  the  leg — the  body 
was  secured  to  the  bed  as  was  previously  done.  In  this  posi- 
tion he  lay  for  three  weeks,  after  which  time  the  splint  was 
removed  and  passive  motion  induced. 

"  At  the  time  of  writing  the  above,  the  boy  was  able  to 
walk  without  crutches,  though  there  is  still  some  lameness — , 
the  foot  is  still  in  an  abducted  position,  with  the  toe  everted, 
giving  him  altogether  an  awkward  appearance. 

"  In  this  case  the  difficulty  did  not  consist  in  the  reduction 
of  the  dislocation,  but  in  retaining  it  in  its  normal  position 
after  reduction  ;  and  it  is  our  opinion  the  injured  limb  should 
always  be  secured  with  a  splint,  the  normal  axis  of  the  leg 
maintained,  and  the  toe  but  slightly  inclined  outwards.  It 
will  be  seen  that  the  splint  in  this  case  was  left  on  somewhat 
longer  than  would  be  required  in  the  majority  of  cases." 

In  the  above  case  it  seems  strange  that  the  toes  remained 
everted  and  the  foot  abducted  after  the  reduction  was  effected, 
unless  the  head  of  the  femur  was  fractured  or  a  notch  was 
broken  out  of  the  rim  of  the  acetabulum. 

Case  CCXV.  of  Dr.  J.  Mason  Warren's  Xnr/i'i<-«l  Observations, 
was  somewhat  similar  to  that  just  quoted.  The  bone  slipped 
out  of  place  in  a  few  minutes  after  it  was  reduced,  while  the 
limb  was  slightly  raised  for  a  more  thorough  inspection.  The 
experiment  of  reduction  and  luxation  was  performed  <cveral 
times  to  see  what  was  the  probable  cause  of  the  easy  recur- 
rence. Slight  crepitus  showed  that  a  fracture  of  the  acetabu- 
lum or  head  of  the  femur  existed,  probably  of  the  upper  and 
back  part  of  the  cotyloid  border.  Hence,  Desault's  fracture 


DISLOCATIONS.  281 

apparatus  \vas  employed  for  three  weeks.  At  the  end  of  that 
time  the  patient  threw  oft'  the  splint,  and  began  to  use  liis  leg. 
While  turning  around  the  bone  slipped  from  its  socket,  and 
in  the  course  of  a  week  the  accident  occurred  a  number  of 
times  upon  the  most  trivial  occasions.  A  permanent  splint 
was  then  put  on,  and  the  leg  kept  quiet  in  a  straight  attitude 
for  several  months.  After  the  fracture  dressing  was  removed 
the  joint  slowly  regained  its  mobility.  Dr.  Warren  pertinently 
remarks  that  if  the  patient  had  passed  into  other  hands  when 
some  of  these  recurrences  of  the  dislocation  took  place  "  it 
might  easily  have  been  urged  that  the  dislocation  had  never 
been  reduced." 

In  cases  of  old  dislocation  of  the  shoulder,  the  accident  re- 
curring over  and  over  again,  there  is  little  skill  required  in 
effecting  a  reduction.  Some  persons  in  whom  the  shoulder  is 
so  affected,  have  learned  to  reduce  the  dislocation  for  them- 
selves, by  reaching  over  a  gate,  taking  hold  of  one  of  the  lower 
bars,  and  hanging  in  this  position,  when  the  mere  weight  of 
the  body  is  sufficient  to  restore  the  parts  to  their  place.  The 
non-professional  brother  of  a  patient  of  my  acquaintance  had 
learned  the  manner  of  reducing  a  frequently  recurring  dislo- 
cated shoulder,  and  performed  this  service  whenever  required. 
Some  loose  jointed  children  practice  dislocating,  wholly  or  in 
part,  some  articulation  of  the  thumb  or  of  the  fingers  ;  the 
reduction  is  performed  with  equal  facility. 

CAUSES  OF  DISLOCATION. —  As  has  been  stated  previously,  ex- 
ternal violence  and  muscular  contraction  are  the  frequent  and 
prevailing  causes  of  dislocation.  A  blow  upon  the  top  of  the 
shoulder,  escaping  the  acromion  but  hitting  the  head  of  the 
humerus,  may  force  the  latter  bone  downwards,  below  the 
glenoid  cavity,  into  the  axillary  or  subglenoid  space.  It  is 
possible  that  the  femur,  when  the  limb  is  in  a  state  of  abduc- 
tion, may  be  driven  downwards  in  the  same  manner,  so  that 
the  head  of  tne  bone  shall  find  a  lodgment  in  the  thyroid  fora- 
men. The  patella  is  known  to  have  been  dislocated  by  a 
direct  blow.  Either  end  of  the  clavicle  may  be  forced  out  of 
articulation  by  direct  violence.  I  reduced  a  luxation  of  one 
coudyle  of  the  jaw,  that  was  produced  by  a  kick. 

The  indirect  force  most  commonly  produces  dislocations, 
whether  the  articulation,  at  which  the  accident  occurs.be  of  one 


282  I  ^LOCATIONS. 

kind  or  another.  A  powerful  force  suddenly  applied  to  the 
elbow,  carrying  the  arm  excessively  upward,  may  rupture  the 
capsular  ligament  of  the  shoulder  joint,  and  thus  open  the 
way  for  a  luxation.  The  hand  thrown  forward  to  break  a 
fall,  may  receive  a  force  which  is  safely  transmitted  through 
the  carpus,  and  shaft  of  the  radius,  without  fracture  or  dislo- 
cation of  those  parts,  but  the  head  of  the  radius  may  be 
wrenched  from  its  connection  with  the  external  condyle.  It 
is  not  always  easy  to  determine  the  essential  cause  of  disloca- 
tion ;  an  injury  is  received  in  some  unknown  manner,  which 
proves  to  be  a  luxation.  The  patient  can  not  positively  tell 
whether  the  violence  was  applied  to  the  arm  or  to  the  shoul- 
der, to  the  hand  or  to  the  elbow.  A  bruise  upon  some  point, 
remote  from  the  luxation  or  directly  upon  the  joint,  may  lead 
to  a  rational  interpretation  of  the  cause,  yet  there  may  In- 
several  contusions,  and  all  be  produced  l>y  forces  independent 
of  that  which  caused  the  dislocation.  Generally  a  limb  in  a 
state  of  luxation  is  a  little  shorter  than  natural,  though  it 
may  be  longer;  in  most  instances  it  is  either  longer  or  shorter, 
and  rarely  retains  the  same  length  as  the  other  limb.  In  a 
dislocation  downwards  of  the  humerus  (subglenoid)  the  arm 
is  lengthened  about  two  inches;  if  the  head  of  the  bone  be 
thrown  under  the  eoracoid  process  (subcoracoid)  the  arm  i< 
lengthened  about  three  quarters  of  an  inch,  and  if  the  dis- 
placement extend  inside  the  eoracoid  process  the  head  of  the 
humerus  rises  toward  the  clavicle  and  the  arm  is  shortened. 
In  dislocations  of  the  hip,  the  leg  is  two  or  three  inches 
shorter  if  the  head  of  the  femur  be  thrown  upon  the  dot-sum 
ilii,  and  the  limb  is  longer  if  the  dislocation  be  downward  into 
the  thyroid  foramen.  In  dislocations  of  a  ginglymoid  articu- 
lation, the  limb  is  rarely  lengthened,  and  is  generally  shortened. 

A  dislocated  limb  always  has  a  constrained  and  distorted 
appearance,  which  is  diagnostic  of  the  injury.  A  dislocation 
of  the  radius  and  ulna  backwards  resembles  a  deformity  lot- 
lowing  a  fracture  of  the  shaft  of  the  humerus  just  above.-  the 
condyles,  yet  the  rigid  state  of  the  parts  involved  in  the  dis- 
location, and  the  mobility  in  fracture,  ought  to  he  sufficiently 
marked  to  remove  doubt  in  anv  case,  t  >  say  nothing  of  other 
distinctive  features  in  each. 

The  pain  and  disagreeable  numb  sensations  attendant  upon 
a  recent  dislocation,  aid  in  the  diagnosis,  t  hough  >uch  signs 


DISLOCATIONS.  283 

are  not  sufficiently  characteristic  of  the  injury  to  settle  a 
question  involved  in  doubt.  Not  much  can  he  determined  by 
the  swelling,  for  other  injuries  have  that  symptom  in  a  greater 
or  less  degree,  the  amount  not  always  depending  upon  the 
severity  of  the  lesion. 

Fractures  near  the  joints  and  sprains  resemble  dislocations. 
A  sprain  is  attended  with  pain,  swelling,  and  stiffness  which . 
may  be  taken  for  the  rigidity  of  luxation.  However,  a  limb 
simply  sprained  can  be  made  to  move  in  all  its  normal  direc- 
tions, and  no  ugly  deformity,  beyond  that  caused  by  the 
swelling,  can  be  discovered.  In  a  fracture  crepituscan  almost 
always  be  elicited,  a  sign  which  is  unmistakable.  Dislocated 
joints  and  even  those  merely  stiffened  from  disuse,  may  be 
made  to  yield  a  creaking,  crackling  noise,  but  it  is  not  the 
sharp,  harsh  grating  sound  known  as  the  genuine  crepitation 
of  fracture. 

It  is  difficult  to  reduce  a  dislocated  bone,  and  when  reduced 
it  will  generally  stay  in  place;  not  so  in  a  difficulty  consisting 
purely  of  a  fracture.  In  the  latter  injury  the  reduction  is 
easy,  and  the  displacement  returns  to  the  parts  as  soon  as  left 
to  themselves.  For  instance,  a  fracture  of  the  neck  of  the 
femur  is  attended  with  shortening,  and,  in  some  instances,  in- 
version of  the  toes — both  marked  features  of  dislocation  of 
the  hip,  yet  in  the  event  of  fracture  the  shortening  could  be 
readily  overcome  by  moderate  extension  ;  and  if  this  force 
was  relaxed,  the  shortening  would  reappear.  In  the  event  of 
dislocation,  the  shortening  could  not  well  be  overcome  and 
the  toes  be  brought  into  their  natural  attitude  without  reduc- 
tion :  and  when  the  head  of  the  bone  was  once  replaced  it 
would  not  leave  its  situation  as  soon  as  the  limb  was  left  to 
itself.  In  addition  to  these  differential  signs,  the  mobility  in 
fracture  and  the  rigidity  in  dislocation,  are  quite  distinctive, 
and,  therefore,  valuable. 

The  sooner  the  investigation  of  an  injury  is  held  after  an 
accident,  the  clearer  will  appear  the  differential  signs ;  and 
the  less  distress  will  be  inflicted  upon  the  patient  in  establish- 
ing the  diagnosis.  If  two  or  three  days  pass  before  the  in- 
jury is  seen  by  the  surgeon,  he  will  be  balked  \yy  the  swelling, 
the  tenderness,  and  the  tumid  condition  of  the  infiltrated  tis- 
sues. It  is  advised  by  Malgaigne.  in  obscure  cases,  to  insert 
a  slender  and  well  tempered  needle  through  the  tissues  to  the 


284  DISLOCATIONS. 

articulation  ;  and  with  its  point  explore  the  structures  of  the 
joint.  If  the  head  of  the  bone  be  in  place  the  progress  of  the 
needle  will  be  arrested  ;  but,  if  out  of  place,  the  hollow  space 
it  once  occupied  will  be  reached,  and  the  diagnosis  established. 
It  is  far  better  to  use  an  exploring  needle  than  to  remain  in 
doubt  concerning  the  nature  of  the  injury.  The  point  of 
penetration  should  be  selected  so  as  not  to  endanger  the  punc- 
ture of  a  large  vessel  or  nerve. 

Sensitive  females,  or  those  possessing  peculiarly  impressible 
nervous  systems,  may  claim  that  they  have  a  dislocated  joint, 
and  simulate  luxation  to  an  extent  likely  to  deceive  the  un- 
wary. The  knee  is  the  joint  most  liable  to  be  attacked  with 
such  symptoms  as  are  generally  the  result  of  hysterical  coin- 
plications.  So  irregular  becomes  the  distribution  of  nerve  in- 
fluences that  the  parts  about  the  joint  may  swell  and  become 
distorted,  or  waste  as  if  struck  with  palsy.  The  patient  claims 
to  have  slipped  and  displaced  a  bone,  and  ever  after  was  un- 
able to  walk  or  even  move  the  joint.  Manipulations  and 
passive  motions  are  attended  with  excruciating  pain.  In 
some  instances  the  rigidity  of  the  articulation  is  well  calcu- 
lated to  mislead,  the  physician  being  convinced  that  no  lesion, 
other  than  luxation,  could  present  such  articular  fixedness. 

These  neuropathic  affections  of  the  joints  are  called  forth 
at  first  by  the  feelings  and  imaginings  of  the  patient,  who 
having  once  or  twice  given  way  to  the  belief  that  she  is  suffer- 
ing from  a  dislocation  or  other  serious  lesion  of  the  joint,  de- 
ceives herself  into  the  full  conviction  of  having  a  real  malady. 
This  feeling  indulged  in  for  a  few  weeks  or  months,  disturlis 
the  nutritive  functions  of  the  part  claimed  to  be  displaced  or 
disordered,  and  in  time  a  real  deformity  exists,  which  is  in 
danger  of  becoming  permanent.  If  the  surgeon  be  persuaded 
that  no  luxation  or  real  defect  exists,  he  may  have  chloroform 
administered  and  go  through  with  the  mock  performance  of 
reducing  a  dislocation,  or  of  executing  some  important  opera- 
tion. Patients  have  thus  been  deceived  into  a  cure  which 
could  not  be  accomplished  in  any  other  way. 

GENERAL  TREATMENT  OF  DISLOCATIONS. — From  what  has  been 
previously  written  it  will  be  seen  that  1  am  in  favor  of  reduc- 
ing dislocated  bones  by  such  gentle  movements  of  the  limb  in 
certain  directions  as  shall  relax  the  muscles  and  brin»>'  the 


4 

DISLOCATIONS.  285 

head  of  the  displaced  bone  into  a  position  favorable  to  its  re- 
turn through  the  same  rent  in  the  capsular  ligament,  that 
permitted  the  egress.  This  is  to  be  accomplished  more  by 
tact  than  by  force — arte  -non  vi.  However,  dislocations  of  the 
ginglymoid  articulations  can  not  be  reduced  without  more  or 
less  force  is  used.  The  power  is  not  to  be  employed  rigidly 
in  a  straight  line,  but  advantage  is  to  be  taken  of  the  muscles, 
relaxing  them  as  much  as  possible,  and  by  twisting  and  rock- 
ing motions  the  impediments  of  bony  prominences  are  to  bo 
overcome.  For  instance,  in  case  of  dislocation  of  the  ulna 
backwards,  extension  from  the  wrist  and  counter-extension 
from  the  shoulder,  with  the  whole  arm  in  a  straight  attitude, 
will  avail  nothing,  except  it  defeat  the  object  to  be  accom- 
plished, unless  force  enough  be  employed  to  break  and  tear 
through  every  obstacle.  The  knee  is  another  joint,  when  lux- 
ated, that  requires  force  to  reduce  it,  yet  the  leg  needs  to  be 
Hexed,  and  the  force  used  against  the  ham,  and  not  upon  the 
foot  with  the  limb  in  a  straight  position.  A  little  coaxing  in 
the  management  of  dislocations,  often  proves  effectual  when 
arbitrary  force  is  obstinately  resisted.  Intelligent  manipula- 
tion manifested  in  accordance  with  a  good  understanding  of 
the  anatomy  and  pathology  of  the  articulation,  will  generally 
succeed  in  reducing  a  dislocation  when  brute  force  would  fail 
or  be  attended  with  unnecessary  suffering  and  lasting  injuries. 
The  accomplished  surgeon  considers  well  every  phase  of 
each  case,  rarely  allowing  himself  to  be  completely  thwarted; 
if  one  method  of  reduction  does  not  succeed,  he  tries  another, 
being  ever  fertile  in  expedients  and  resources,  lie  even  en- 
lists the  power  of  the  muscles  to  assist  in  the  work  of  reduc- 
tion. The  expert  bone-setter  does  not,  when  called  to  treat  a 
dislocation,  first  look  about  for  pulleys  and  other  contrivances 
for  multiplying  force  that  he  may  violently  drag  the  bone  back 
into  place,  regardless  of  consequences.  The  ignorant  and  in- 
experienced are  ever  embarrassed;  and  in  order  to  mask  their 
inefficiency,  the}'  often  resort  to  violent  measures  that  are  en- 
tirely unnecessary.  Natural  prominences  about  the  joints 
have  been  taken  for  deformities ;  and  a  simply  sprained  articu- 
lation has  been  subjected  to  the  stretching  influence  of  Jarvis' 
Adjuster.  The  physician  who  has  courage  to  acknowledge 
his  incompetency  to  treat  a  surgical  injury  is  a  moral  hero 
who  will  not  go  through  the  world  with  merits  unrewarded. 


286  DISLOCATIONS. 

The  most  skillful  and  experienced  surgeon  is  often  baffled  or 
utterly  thwarted  iu  his  efforts  to  reduce  a  dislocation  ;  and  his 
failures  teach  him  to  be  charitable  in  passing  criticisms  upon 
those  whose  opportunities  to  acquire  and  put  in  practice  sur- 
gical knowledge  have  been  necessarily  limited. 

With  the  patient  under  chloroform  the  majority  of  luxa- 
tions will  yield  to  well  directed  and  persevering  manipulation  : 
if  that  fails,  extension  and  counter-extension  should  be  made 
by  the  hands  of  assistants,  and  while  these  forces  are  being 
applied,  the  surgeon  should  give  proper  directions,  and  en- 
deavor with  his  own  hands  to  rotate  the  limb  or  to  impart 
such  movements  to  it  as  shall  favor  reduction. 

These  efforts  having  failed,  the  surgeon  may  deem  it  advis- 
able to  resort  to  Jarvis'  Adjuster,  the  pulleys,  or  some  other 
contrivance  for  multiplying  force.  A  strong  cotton  handker- 
chief, or  a  wide  strip  of  iirm  muslin  may  be  made  fast  to  the 
wrist  (if  force  i&  to  be  applied  to  the  arm)  by  the  common 
double  slip-knot  or  what  is  called  the  "  clove  hitch,"  for  the 
application  of  the  extending  force  ;  a  wide  towel  or  folded  sheet 
put  around  the  chest,  just  under  the  arm,  will  do  for  making 
the  counter-extension.  Two  large  staples  or  spikes  driven 
into  door  posts  or  window  sills,  or  any  firm  fastenings  in  a 
wood  shed  or  back  room,  a  few  feet  distance  from  one  another. 
will  answer  for  points  to  make  fast  to  when  everything  is  in 
readiness.  Let  the  towel  or  sheet  surrounding  the  patient's 
chest  be  tied  to  one  spike  or  staple,  and  a  strong  cord  or  rope 
doubled  upon  itself,  be  tied  between  the  other  spike  or  staple 
and  the  extending  handkerchief  placed  on  the  patient's  wrist. 
A  stick  or  cane  inserted  between  the  two  thongs  of  the 
double  rope  may  now  be  revolved  as  in  a  Spanish  windlass, 
until  the  extending  bands  are  made  tort.  It  will  be  seen  that 
great  extending  and  counter-extending  force  can,  in  this  way, 
be  brought  to  bear  upon  the  arm.  The  contrivance  is  so 
simple  that  it  can  be  gotten  up  in  a  few  minutes  in  any  farm 
house;  and  it  serves  all  the  purposes  of  costly  blocks  and 
pulleys.  Since  the  discovery  of  anaesthesia  and  rational  man- 
ipulation, there  is  seldom  a  call  for  such  mechanical  contriv- 
ances as  constituted  a  necessary  part  of  the  surgeon's  para- 
phernalia a  half  century  ago.  I  have  reduced  dislocations  in 
subjects  of  great  muscularity,  without  assistance  or  appliance- ; 
and  although  I  have  possessed  a  Jarvis'  Adjuster  for  fiftn-u 


DISLOCATIONS.  287 

years  I  have  rarely  put  it  into  use.  I  begin  to  regard  it  as 
entirely  superfluous. 

It  was  formerly  considered  necessary  to  subdue  muscular 
tension  and  to  reduce  the  powers  of  the  system  by  the  use  of 
warm  baths,  venesection  and  tartarized  antimony;  but  the 
discovery  of  anaesthesia  has  entirely  superseded  those  agents. 
The  forcible,  prolonged,  agitating  and  painful  attempts  to  re- 
duce dislocations,  which  Avere  common  to  older  surgery,  are 
scarcely  heard  of  now.  The  old  notion  that  the  muscles  had 
to  be  "tired  out"  by  the  prolonged  traction  of  a  number  of 
men,  or  by  various  mechanical  contrivances,  some  of  them  of 
the  most  ludicrous  nature,  which  may  be  seen  depicted  in 
old  books  of  surgery,  has  been  almost  entirely  supplanted  by 
more  rational  ideas  and  sounder  principles. 

In  France  an  instrument  called  a  dynamometer  is  used  in 
connection  with  the  pulleys,  in  order  that  the  precise  force 
•employed  may  be  accurately  measured.  This  is  a  refinement 
that  has  not  been  introduced  into  American  practice.  Inas- 
much as  different  degrees  of  force  are  required  in  individual 
cases,  and  it  never  having  been  ascertained  how  much  force 
may  be  safely  applied  in  a  given  case,  the  instrument  could 
have  no  practical  value. 

It  should  be  remarked  for  the  benefit  of  those  who  may 
employ  pulley  force,  that  the  surgeon  is  to  watch  the  condition 
of  the  joint  while  the  extension  is  being  made  ;  and  as  soon 
as  the  head  of  the  bone  seems  to  be  opposite  the  empty  ar- 
ticular cavity,  he  is  to  order  the  extension  to  be  relaxed,  and 
at  the  same  time  he  completes  the  reduction  by  pressing  or 
pulling  the  bone  into  place.  If  he  fails  to  return  the  head  of 
the  bone  to  its  normal  position,  and  it  sinks  back  into  its  ne\v 
formed  bed,  the  pulley  force  is  to  be  renewed,  and  a  fresh 
attempt  made  to  return  the  bone  at  the  nick  of  time  when  the 
assistant  relaxes  the  extending  cord.  The  handkerchief  or 
bandage  applied  above  the  wrist,  elbow,  ankle,  or  knee,  as  a 
fastening  to  hitch  the  ropes  to,  may,  in  prolonged  efforts  at 
reduction,  excoriate  the  constricted  parts,  and  the  wounds  be 
followed  by  dangerous  sloughing.  It  is  to  be  borne  in  mind, 
therefore,  that  there  are  worse  evils  than  a  dislocated  bone ; 
and  a  surgeon  might  bring  discredit  upon  himself  by  hopelessly 
ruining  a  limb,  even  if  he  succeeds  in  the  reduction  by  the 
exhibition  of  unwarranted  violence. 


288  DISLOCATIONS. 

Reduction  having  been  accomplished,  the  position  of  the 
replaced  bone  must  be  maintained  by  bandages,  or  slings,  for 
a  certain  period;  generally  a  week  is  sufficient  to  confine  most 
of  the  joints;  the  shoulder  should  be  kept  in  a  state  of  repose 
for  two  weeks.  High  grades  of  inflammation  require  topical 
applications  of  evaporating  and  anodyne  lotions.  In  the 
event  of  suppuration  the  pus  should  be  evacuated  at  a  proper 
time,  and  efforts  made  to  prevent  anchylosis. 

Tenotomy  has  been  performed  in  order  to  overcome  what 
seemed  to  be  the  chief  resistance  to  reduction.  The  tendo- 
Achillis  has  been  subcutaneously  divided  to  facilitate  the  re- 
turn of  the  foot  to  its  normal  place  when  luxated  backwards  ; 
and  so  have  the  tendons  of  the  thumb  been  served  to  accom- 
plish reduction.  In  regard  to  these  operations  I  nun-  say, 
that  there  is  no  serious  objection  to  tenotomy  if  reduction 
can  not  be  effected  in  any  other  way ;  but  with  the  free  use  of 
an  anaesthetic,  it  is  not  probable  that  such  measures  are  over 
necessary. 

In  compound  and  complicated  dislocations  there  can  be  no 
definite  rules  which  will  reach  many  cases.  The  lesions  are 
generally  of  such  a  serious  and  complex  nature,  that  the  sur- 
geon must  manage  each  according  to  its  individual  peculiari- 
ties. A  joint  badly  crushed  as  well  as  dislocated,  with  injury 
of  the  passing  vessels  and  nerves,  may  require  amputation 'or 
resection  to  save  life.  However,  there  is  generally  no  neces- 
sity for  haste  in  resorting  to  extreme  measures  unless  the  dis- 
organized condition  of  the  limb  demands  prompt  action.  The 
conservative  spirit  of  modern  surgery  has  saved  limbs  that 
would  have  been  sacrificed  at  once  in  Sir  Astley  Cooper's 
time.  Loose  pieces  of  bone  deprived  of  nutritive  connections 
should  be  removed  in  compound  injuries,  and  then  if  the  re- 
duction be  accomplished,  and  the  joint  treated  like  a  fracture 
or  in  accordance  with  the  demands  of  the  case,  a  serviceable 
limb  may  be  saved  to  the  patient.  Compound  dislocation  of 
the  knee,  complicated  with  fracture  of  the  patella,  and  the 
condyles  of  the  femur,  generally  demands  amputation  to  save 
life.  The  dangers  from  primary  shock,  subsequent  pyaemia, 
and  irritative  fever,  constitute  well  grounded  objections  to  any 
argument  advanced  in  favor  of  attempting  to  save  the  limb. 

'If  a  dislocation  be  complicated  with  a  fracture,  the  luxation 
should  be  overcome  first,  if  possible,  and  then  the  fracture 


DISLOCATIONS.  289 

may  be  treated  as  a  simple  injury,  for  a  dislocated  bone  left 
until  a  fracture  has  united,  is  not  easy  to  be  returned  to  place. 
The  older  Warren,  of  Boston,  once  had  a  case  of  shoulder 
dislocation  and  fracture  of  the  humerus  on  the  eameside; 
and  he  was  unable  to  reduce  the  luxation  until  the  broken 
bone  was  repaired.  This  course  is  commended  by  Malgaigne, 
and  it  even  might  be  necessary  when  the  fracture  was  so  near 
the  head  of  the  bone  as  to  render  it  impossible  to  overcome 
the  dislocation  until  the  fragments  of  the  humerus  had  united 
so  as  to  make  a  lever  of  the  arm. 

Mv  experience  with  compound  dislocations  leads  me  to 
commend  an  attempt  to  save  the  limb  without  amputation. 
Two  years  ago  I  was  called  to  an  injured  elbow  in  which  the 
radius  and  ulna  were  projecting  through  the  flesh  on  the  pos- 
terior aspect  of  the  arm.  I  gave  the  patient  chloroform,  and 
rather  easily  pulled  the  luxated  bones  into  position.  1  dressed 
the  limb  in  a  semi  flexed  position,  and  left  the  wound  in  the 
skin  as  it  was.  inflammation  was  held  repressed  by  the  use 
of  cooling  lotions,  and  the  internal  use  of  chloral  hydrate. 
Considerable  suppuration  attended  the  healing  process,  and 
the  elbow  was  somewhat  stiff.  In  this  case  there  appeared 
no  excuse  tor  amputation. 

A  boy  was  playing  base  ball  and  received  a  compound  dis- 
location of  the  ring  finger  at  the  knuckle  joint.  It  required 
great  traction  to  pull  the  luxated  bone  into  place.  However, 
with  force  and  manipulation  I  succeeded  in  the  reduction.  I 
bound  the  linger  in  splints,  and  kept  the  lesion  wet  with  cool- 
ing lotions.  In  four  weeks  the  linger  was  well,  yet  somewhat 
stiff  at  the  injured  joint.  Passive  motion  for  three  months 
completely  restored  the  functions  of  the  joint. 

I  was  once  called  to  Dr.  McKinney,  of  Defiance,  O.  lie 
had  received  a  compound  dislocation  of  the  ankle  the  day 
previously.  Amputation  had  been  advised,  but  I  opposed 
such  a  procedure.  The  patient  was  a  very  large  man  and  the 
injured  limb  swelled  prodigiously.  The  dislocation  was  re- 
duced, and  the  limb  left  without  splints  or  other  dressings 
except  pledgets  of  lint  laid  upon  the  the  wound.  There  ap- 
peared to  be  no  disposition  to  a  re-dislocation.  The  swelling 
of  the  leg  was  so  great  that  phlyctena>  appeared  and  gangrene 
threatened.  The  patient  made  a  good  recovery,  yet  with  re- 
stricted action  of  the  ankle-joint. 
19 


CHAPTER  II. 


DISLOCATIONS  OF   PARTICULAR  JOINTS. 


FIG.  106. 


DISLOCATION  OF  THE   JA\\r. 

The  under  jaw  is  articulated,  through  its  condyles,  with  the 
glenoid  cavities  of  the  temporal  bones.  In  each  temporo- 
maxillary  joint  is  a  bi-concuve  fibre-cartilage,  with  synovial 
membrane  on  both  surfaces,  which  facilitates  the  various  mo- 
tions of  the  articulation,  and  in  a  measure  prevents  luxation, 
for  its  elastic  substance  lessens  shocks,  and  its  shape  deepens 

the  articular  cavity.  The  glenoid 
cavities  are  bounded  in  front  by 
ridges  of  bone  called  the  eminentise 
articulares  ;  and  in  laughing,  yawn- 
ing, and  other  forward  movements 
of  the  lower  jaw,  the  condyles  rest 
upon  these  bony  prominences;  but 
the  ligaments  of  the  temporo-max- 
illary  joints,  prevent  the  condyles 
from  dropping  into  the  zygomatic 
fossae  in  front  of  the  emin entire  ar- 
ticulares, or  from  becoming  dislo- 
cated. However,  an  extreme  downward  and  forward  motion 
of  the  jaw,  as  sometimes  takes  place  in  gaping,  ruptures  the 
ligaments,  and  luxation  ensues.  Muscular  action,  then,  is  suf- 
ficient to  produce  the  lesion.  Sir  Astley  Cooper  reports  the 
case  of  a  boy  who  had  his  jaw  dislocated  by  an  apple  forced 
into  his  mouth  ;  and  Dr.  Physick,  of  Philadelphia,  knew  a 
woman  to  dislocate  her  jaw  while  scolding  her  husband.  Dr. 
E.  Andrews,  of  Michigan,  reports  a  case  in  the  Peninsular 
Journal  of  Medicine,  in  which  a  patient  while  vomiting  from 
the  effects  of  lobelia,  received  a  dislocation  of  the  jaw ;  other 
emetics  of  the  same  kind  had  been  frequently  taken,  but  no 


Dislocation  of  the  lower  jaw. 


OF  THE  JAW.  291 

ill  effects  had  followed  except  a  sensation  of  slight  spasm  at 
the  joint.  Malgaigne  met  with  four  cases  of  luxation  of  the 
jaw  from  vomiting,  and  five  from  convulsions.  Dentists  not 
infrequently  dislocate  the  jaw  on  one  or  both  sides  while  en- 
gaged in  extracting  teeth,  removing  old  fangs,  and  even  while 
excavating  and  filling.  Dr.  Gilbert,  of  Buffalo,  in  a  Th<. <'•••< 
upon  Dislocation  of  the  Inferior  Maxillary,  relates  a  case  of  lux- 
ation of  both  condyles  forward,  under  the  zygomatic  arches, 
which  occurred  while  he  was  taking  an  impression  of  the 
lower  alveolar  ridges,  for  the  purpose  of  making  an  artificial 
set  of  teeth. 

Direct  violence  occasionally  produces  luxation  of  the  lower 
jaw.  A  heavy  lateral  blow,  or  the  kick  of  a  horse  or  mule, 
the  force  being  directed  forwards  as  well  as  laterally,  may 
dislocate  one  or  both  condyles. 

Children  and  elderly  persons  are  not  subject  to  this  accident, 
though  a  case  in  one  of  the  extremes  of  age  is  occasionally 
reported.  Nelaton  found  a  dislocation  of  the  jaw  in  a  person 
above  seventy,  whose  gums  were  toothless. 

Luxations  of  the  jaw  occur  most  frequently  in  persons  from 
fifteen  to  thirty-five  years  of  age  ;  and  in  females  much  oftener 
than  in  males.  A  laxity  of  the  ligamentous  structures  about 
the  articulations  favors  dislocation,  whether  the  subject  be  of 
one  sex  or  the  other.  As  soon  as  the  condyles  become  thrown 
slightly  in  front  of  the  articular  eminences,  the  jaw  is  spas- 
modically forced  forward  by  the  combined  action  of  the  mas- 
seters  and  internal  pterygoid  muscles. 

A  backward  dislocation  is  impossible  unless  the  osseous 
structure  of  the  external  ear  is  broken  at  the  same  time.  Dis- 
location of  one  condyle  forward,  the  other  being  left  in  place, 
is  an  accident  of  not  extremely  rare  occurrence;  though  both 
condyles  are  much  more  frequentl}'  luxated  in  one  injury. 

The  symptoms  of  dislocated  jaw  are  so  marked  and  charac- 
teristic, that,  says  Robert  Wm.  Smith,  "were  there  not  re- 
corded cases  to  the  contrary,  we  could  scarcely  suppose  it 
possible  that  the  true  nature  of  the  accident  could  be  over- 
looked. *  *  The  mouth  remains  widely  opened,  and  the  indi- 
vidual is  unable  to  close  it ;  the  incisor  teeth  of  the  lower  pro- 
ject beyond  those  of  the  upper  jaw ;  the  saliva  flows  from 
the  mouth  involuntarily  and  profusely ;  speech  is  difficult, 
and  the  pronunciation  of  labial  consonants  impossible ;  deglu- 


292  DISLOCATIONS. 

tition  can  not  be  performed,  and  the  motions  of  the  tongue 
are  limited." 

"  The  masseteric  regions  of  the  cheeks  are  flattened,  a  de- 
pression is  observed  in  front  of  the  auditory  canal,  immedi- 
ately below  the  horizontal  root  of  the  zygoma,  and  the  finger 
can  be  sunk  into  the  parotid  space.  The  coronoid  process 
forms  below  the  malar  bone,  a  prominence  which  is  very  visible 
externally,  but  which  is  most  distinctly 
felt  through  the  mouth." 

"  There  is  likewise  an- evident  fullness 
in  the  temporal  fossa,  between  the  eye- 
brow and  the  ear,  immediately  above 
the  zygoma.  This  prominence  (which 
does  not  seem  to  have  been  noticed  by 
any  writer  except  Mr.  Adams)  appears 
to  be  thus  produced :  As  soon  as  the 
condyle  has  cleared  the  articular  emin- 
ence, it  at  once  becomes  placed  upon  a 
higher  level  than  the  apex  of  the  coro- 
!fiaryioD'  noid  process ;  it  is  elevated  in  the  same 

proportion   as   the  coronoid  process   is 

depressed.  It  thus  comes  into  contact  with  and  pushes  up- 
wards the  posterior  fibres  of  the  temporal  muscle,  which  pass 
horizontally,  or  nearly  so,  over  the  pulley-shaped  surface  of 
the  zygoma.  To  the  displacement  and  stretching  of  these 
fibres  over  the  upper  surface  of  the  condyle,  the  prominence 
alluded  to  is,  I  conceive,  to  be  ascribed." 

The  coronoid  process  can  be  felt  through  the  cheek,  or 
within  the  mouth;  and  the  relation  of  the  teeth  is  altered. 
The  pain  in  a  recent  case  is  intense ;  but  becomes  mitigated 
in  the  course  of  a  few  days  in  cases  left  unreduced. 

When  one  condyle  is  dislocated  the  anterior  arch  of  the 
jaw  inclines  to  the  right  or  left  side  as  the  case  may  be,  giv- 
ing the  lower  part  of  the  face  a  distorted  appearance.  The 
mouth  is  not  held  wide  open,  as  in  the  double  dislocation,  but 
the  parallelism  of  the  teeth  is  destroyed,  and  the  jaw  i=  rigidly 
fixed  in  the  distorted  state. 

When  luxation  of  the  condyles  is  left  unreduced  for  several 
weeks  or  mouths,  the  chin  gradually  becomes  elevated,  the 
patient  is  enabled  to  close  the  mouth,  the  involuntary  flow  of 
saliva  ceases,  the  faculty  of  speech  is  regained,  and  most  of 


OF  THE  JAW.  293 

the  characteristic  signs  of  the  nature  of  the  injury  disappear; 
hut  the  projection  of  the  chin,  and  the  advance  of  the  lo\ver 
incisor  teeth  still  remain,  making  the  lower  segment  of  the 
face  rather  unsightly.  In  fact,  the  general  mobility  of  the  jaw 
is  never  fully  recovered,  if  the  bone  be  left  unreduced. 

Mr.  Hey,  in  speaking  of  dislocation  of  one  condyle,  does 
not  admit  that  the  chin  is  carried  off  to  the  side  opposite  the 
lesion,  but  declares  that  he  could  see  no  alteration  in  the  posi- 
tion of  the  chin.  The  symptom  most  diagnostic,  according 
to  his  description,  is  a  small  hollow  or  depression  which  can 
he  felt  hchind  the  eondyle  that  is  dislocated  ;  and  the  other 
side  is  natural  or  free  from  any  such  empty  space. 

When  the  mouth  is  open  to  its  utmost  extent,  the  tips  or 
extremities  of  the  condyles  rest  on  the  articular  eminences 
which  bound  the  glenoid  cavity  in  front ;  and  being  poised  on 
those  eminences,  the  muscles  have  an  opportunity  to  jerk  the 
condyles  in  front  of  those  ridges.  Even  if  the  masseters  and 
pterygoids  hold  steadily,  constituting  a  fulcrum,  the  chin  de- 
pressing muscles,  acting  on  the  long  arm  of  the  lever,  may 
readily  accomplish  the  displacement  of  the  condyles  forward. 
This  view  of  the  mechanism  of  the  under  jaw,  explains  why 
gaping  produces  luxation  oftener  than  all  other  causes  com- 
bined. Besides,  it  is  common  for  the  muscles  of  the  neck  and 
lace  to  act  irregularly  during  the  effort  of  yawning. 

Keduction  of  a  dislocated  jaw  has  been  effected  after  the 
hone  has  been  out  of  place  several  weeks,  and  even  months. 
There  is  no  objection  to  an  attempt  being  made  at  reduction, 
even  if  six  months  have  elapsed  from  the  time  of  the  acci- 
dent. However,  it  might  be  difficult  to  keep  the  bone  in  place 
after  it  had  been  luxated  so  long;  and  after  the  implicated 
]  »arts  have  become  accustomed  to  their  new  relations,  there  is 
no  longer  a  pressing  demand  for  surgical  interference.  The 
best  time  to  effect  reduction  is  immediately  after  the  accident ; 
and  the  patient,  though  unable  to  speak,  is  frantic  for  relief. 

TREATMENT. — To  reduce  a  dislocated  jaw  of  recent  occur- 
rence no  chloroform  is  generally  needed.  The  patient  is  to 
be  seated  on  a  low  stool,  with  his  head  resting  against  an 
assistant's  breast;  the  surgeon  places  himself  in  front  of  the 
patient,  and  inserts  his  thumbs,  previously  wrapped  with 
pieces  of  cloth,  into  the  mouth  as  far  back  as  possible  and 


•294  DISLOCATIONS. 

presses  upon  the  lower  molars,  while  the  fingers  heneath  the 
chin  elevate  the  anterior  extremity  of  the  dislocated  hone. 
The  thumbs,  if  they  were  strong  enough,  -\vonld  depress  the 
condyles  helow  the  articular  eminences  and  the  internal  ptery- 
goids  would  snap  them  into  place ;  but  the  assistance  of  the 
ringers,  acting  on  the  anterior  portion  of  the  bone  as  u  lever, 
i-  required  to  overcome  the  power  of  the  temporal,  masseter, 
and  internal  pterygoid  muscles.  Each  thumb  is  not  only  a 
fulcrum,  but  it  is  made  a  power  to  depress  the  back  part  of 
the  jaw  and  disengage  it  from  the  zygomatic  fossa.  By  this 
double  power  exerted  advantageously  by  the  thumbs  and  fin- 
gers the  reduction  can  generally  be  accomplished  in  a  brief 
space  of  time.  The  jaw  needs  pulling  forwards  a  little  in  the 
effort  at  reduction,  in  order  to  facilitate  the  escape  of  the  pro- 
jecting condyles  from  the  cavities  in  which  they  have  been 
re-ting.  As  the  surgeon  feels  the  movement  that  is  to  result 
in  reduction,  he  quickly  slips  his  thumbs  between  the  teeth 
and  cheeks  to  escape  the  effects  of  the  sudden  closure  of  the 
jaws.  The  first  time  I  attempted  this  feat  the  side  of  each 
thumb  was  pinched  into  a  "  blood-blister." 

If  trouble  is  experienced  in  this  attempt  without  chloroform, 
the  patient  may  be  brought  under  the  influence  of  anaesthesia, 
when  less  force  is  required  to  effect  the  reduction,  and  the 
muscles  being  relaxed  there  is  less  danger  of  receiving  a  bite 
at  the  time  the  coudyles  slip  into  pl;< 

Another  method  of  reducing  dislocations  of  the  under-jaw 
is  to  place  a  couple  of  vial  corks  or  pieces  of  soft  wood  as  far 
back  between  the  grinders  as  possible,  each  to  perform  the 
part  of  a  fulcrum,  and  then  with  the  hands  i»r  a  strap  beneath 
the  chin,  exert  sufficient  upward  force  to  pry  the  condyles 
downwards  to  the  level  of  the  articular  eminences  where  the 
muscles  can  pull  the  bone  into  place.  This  plan  is  executed 
while  the  patient  sits  on  the  floor,  with  his  head  resting  be- 
tween the  knees  of  the  surgeon  who  sits  in  a  chair  behind  the 
person,  operated  upon.  M.  Nelaton  has  reduced  dislocations 
of  the  inferior  maxillary,  while  standing  behind  his  patient, 
by  resting  his  fingers  against  the  mastoid  processes,  and  with 
nis  thumbs  upon  the  projecting  coronoid  processes,  forcing 
them  downward  to  a  point  where  the  contracting  muscles 
could  finish  the  reduction.  This  manueuvre  could  hardly  be 


OF  THE  JAW.  295 

•accomplished  unless  the  patient  were  well  under  the  influence 
of  an  anaesthetic. 

An  old  plan  was  to  use  pieces  of  wood  the  size  of  a  narrow 
ruler,  as  levers  in  the  mouth  to  depress  the  angles  of  the  jaw 
sufficiently  to  effect  reduction.  In  the  case  of  Mrs.  Harts- 
horne  who  dislocated  her  jaw  at  the  Sherman  House,  while 
gaping,  I  found  it  necessary  to  use  a  lever  of  wood  to  disen- 
gage one  condyle.  lier  husband  would  not  allow  me  to  employ 
chloroform  ;  and  one  of  my  thumbs  was  suffering  from  a 
sprain,  so  that  I  could  not  exert  sufficient  force  to  dislodge  the 
condyle  from  its  abnormal  bed. 

There  is  no  objection  to  reducing  one  side  at  a  time,  if  the 
operator  has  not  power  in  his  hands  to  accomplish  the  full  re- 
duction at  once.  The  prudent  surgeon  will  employ  force 
with  care,  in  reducing  dislocations,  and  inflict  as  little  damage 
upon  the  patient  as  possible.  Reluxation  should  be  guarded 
against  by  the  use  of  a  bandage  over  the  head  and  under  the 
chin  to  prevent  the  mouth  being  opened  too  wide  either  while 
eating,  gaping,  laughing,  or  sleeping.  A  handkerchief  folded, 
and,  after  passing  under  the  chin,  tied  on  the  top  of  the  head, 
serves  to  prevent  a  wide  separation  of  the  jaws,  and  to  remind 
the  patient  that  the  danger  of  reluxation  still  exists.  The  re- 
tentive means  may  be  employed  a  week  or  ten  days;  and  in 
the  event  of  a  second  accident  and  successful  reduction,  the 
bandage  should  be  worn  for  six  weeks.  The  jaws  are  not  to 
be  so  firmly  closed  by  the  retentive  dressing  as  to  prevent  the 
taking  of  food. 

I  am.  acquainted  with  a  case  of  recurring  luxation  of  the 
interior  maxillary;  and  the  patient  himself,  after  having  it 
reduced  a  few  times,  learned  the  art  of  replacing  the  bone. 
He  generally  employs  a  wooden  roller  of  the  diameter  of  a 
pen-holder,  two  inches  and  a  half  long,  as  a  fulcrum  between 
the  molar  teeth,  while  with  the  hands  he  elevates  the  chin 
and  forces  the  jaw  back  into  its  sockets.  He  says  the  bone 
was  first  dislocated  when  he  was  young.  A  brother  playfully 
struck  him  on  the  chin  while  he  was  in  the  act  of  gaping. 
Relaxation  took  place  in  a  week  after  the  first  reduction  ;  and 
ihe  recurrence  has  been  frequent  ever  since.  He  wore  a  gum 
elastic  bandage  over  the  head  and  under  the  chin  for  a  year 
or  more,  and  although  the  number  of  luxations  decreased  the 
casualty  was  not  wholly  prevented.  Finding  that  the  dis- 


296  DISLOCATIONS. 

placement  of  the  jaw  at  length  gave  very  little  pain,  and  that 
he  could  return  the  bone  to  place  without  difficulty,  lie  took 
no  further  special  precaution  against  the  accident. 

If  an  ancient  dislocation  of  the  inferior  maxillary  disfigured 
the  patient,  and  was  the  source  of  pain  and  other  serious  an- 
noyances, the  subcutaneous  section  of  the  masseters  might 
allow  of  reduction ;  and  if  there  still  existed  formidable  ob- 
stacles to  a  return  of  the  bone,  the  temporal  and  internal 
pterygoids  might  be  divided,  leaving  no  muscular  resistance 
to  reduction. 

Sub-luxation  of  the  lower  jaw  is  a  species  of  displacement 
not  exceedingly  rare,  especially  in  persons  who  possess  a  lax 
state  of  the  ligaments.  The  difficulty  is  somewhat  trouble- 
some, for  the  patient  is  not  able  to  close  the  mouth  until  the 
condyles  are  replaced.  Sir  Astley  Cooper  thought  the  acci- 
dent depended  upon  the  condyle  slipping  off  from  the  inter- 
articular  cartilage,  but  in  a  case  I  had  an  opportunity  to  ex- 
amine, I  was  confident  the  cartilage  followed  the  condyle,  and 
its  concave  centre  impinged  on  the  articular  eminence  in  front 
of  the  glenoid  cavity.  Bransby  B.  Cooper  states  that  "  the 
interarticular  cartilage  is  always  displaced  with  the  condyloid 
process  of  the  bone." 

Very  little  skill  is  required  to  overcome  a  sub-luxation. 
Depression  of  the  jaw,  together  with  lateral  motion,  relieves 
the  "hitch,"  and  the  muscles  replace  the  bone,  and  the  inter - 
articular  cartilage.  No  ligament  or  other  tissue  is  lacerated, 
therefore  it  is  useless  to  employ  a  retentive  dressing.  Bathing 
the  maxillary  joints  frequently  in  cold  water  or  astringent 
lotions,  might  prevent  a  recurrence  of  the  displacement.  A 
spasmodic  contraction  of  the  digastric  and  genio-hyoid  mus- 
cles while  gaping  in  cold  weather,  has  been  regarded  as  a  sub 
luxation,  but  it  is  a  difficulty  quite  distinct  and  different  from 
articular  displacement.  The  spasmodic  state  leaves  the  mus- 
cles sore  beneath  the  chin,  and  in  sub-luxation  the  soreness  is 
confined  to  the  region  of  the  articulation. 


CHAPTER   [II. 
DISLOCATION  OF  THE  VERTEBRA. 


The  intricate  articular  connections  between  the  bones  com- 
posing the  spinal  column,  render  uucopplicated  dislocations 
of  the  vertebrae  exceedingly  rare.  Sir  Astley  Cooper  says  : 
"  I  have  never  witnessed  a  separation  of  one  vertebra  from 
another  through  the  intervertebral  substance,  without  fracture 
of  the  articular  processes  ;  or,  if  those  processes  remain  un- 
broken, without  a  fracture  through  the  bodies  of  the  vertebrae." 
Other  surgeons  and  surgical  writers  have  declared  that  a  dis- 
location can  not  occur  anywhere  in  the  vertebral  column 
without  the  concurrence  of  fracture;  and  any  anatomical 
student  who  has  attempted  to  disarticulate  the  vertebral  chain 
in  a  fresh  subject,  has  been -impressed  with  the  difficulties  at- 
tendant upon  such  separation.  The  bones  interlock  and  over- 
lap to  a  degree  that  seems  to  forbid  luxation ;  and  the  fibrous 
structures  which  bind  the  bodies  of  these  bones  and  their  pro- 
cesses together,  seem  to  be  stronger  than  the  osseous  material 
itself.  However,  there  have  been  reported  during  the  last 
few  years  a  number  of  well  authenticated  dislocations  of  the 
vertebrae,  hi  different  regions  of  the  column. 

It  is  not  extremely  rare  to  find  luxations  of  the  vertebrae 
from  disease,  the  process  of  displacement  being  gradual,  and 
the  result  anchylosis  or  death.  Some  years  ago  I  was  called 
to  a  lady  who  had  been  having  the  head  drawn  forwards  and 
to  one  side1  until  the  left  ear  rested  between  the  nipple  and 
the  armpit  of  the  corresponding  side  of  the  body.  The  ex- 
traordinary contraction  had  wrenched  at  least  three  of  the 
•cervical  vertebwe  from  their  articulations,  and  greatly  dis- 
torted two  others.  But  this  and  similar  cases  do  not  properly 
belong  to  the  subject  of  luxations,  for  they  do  not  occur  sud- 

(297) 


298  DISLOCATIONS. 

denly  from  accidental  violence,  and  are  not  amenable  to  the 
treatment  usually  employed  to  replace  dislocated  bones. 

In  1856  I  was  summoned  to  an  Irishman  who  had  fallen  from 
a  chamber  window  to  the  ground,  head  foremost.  I  found  the 
patient  with  his  head  twisted  to  one  side  and  rigidly  held  in 
that  position,  l^e  uttered  cries  of  distress,  and  called  lustily 
for  relief:  "A  stitch  in  my  neck,  docther,  a  stitch  in  my 
neck."  I  took  hold  of  his  ears  and  endeavored  to  pull  and 
twist  his  head  into  its  natural  position,  but  was  unable  to  ac- 
complish my  object.  I  could  feel  a  bony  displacement  to  ex- 
ist between  the  third  and  fourth  vertebrae,  by  pressing  my 
fingers  into  the  soft  structures  of  the  neck,  though  I  was  un- 
able to  discover  the  exact  nature  or  extent  of  the  luxation. 
Perhaps  another  vertebra  was  implicated  in  the  displacement. 
By  the  help  of  assistants  who  laid  hold  of  the  patient's  head 
and  feet  and  made  powerful  extension  and  counter-extension, 
together  with  some  twisting  motion,  reduction,  which  was  at- 
tended with  an  audible  snap,  was  accomplished.  The  patient 
then  moved  his  head  and  neck  with  ease  and  complained  no 
more  of  sharp  pain.  He  suffered  from  great  soreness  in  the 
neck  for  a  week  or  more,  yet  recovered  without  physical  de- 
fect or  lasting  functional  impairment.  I  am  quite  sure  no 
process  of  bone  was  broken  ;  and  that  the  injury  was  a  simple 
luxation,  occurring  between  two  ox  more  of  the  cervical  ver- 
tebrae. 

The  Lancet  for  '49  contains  the  report  of  a  case  of  disloca- 
tion of  the  cervical  vertebrae  in  a  seaman,  who  in  descending 
the  fore-ladder  caught  his  foot  and  fell  forwards,  striking  on 
the  right  side  of  the  head,  without  inflicting  any  wound  on 
the  scalp.  "  When  taken  up,  he  was  found  to  be  quite  help- 
less, and  on  being  brought  into  the  sick-berth,  the  chief  seat 
of  pain  was  referred  to  the  back  of  the  neck,  which,  on  ex- 
amination, presented  considerable  irregularity  of  the  spinous 
processes  of  the  fifth  and  sixth  cervical  veitcbne,  with  a  bulg- 
ing of  the  muscles  on  the  right  side,  corresponding  to  the 
position  of  the  transverse  processes  of  the  above-named  ver- 
tebra." Head  and  neck  rigid,  face  turned  toward  the  point 
of  the  shoulder,  and  bent  forward;  respiration  natural,  and 
questions  answered  coherently,  though  there  was  considerable 
paralysis  of  the  extremities  Kxtension  and  counter-exten- 
sion with  pressure  made  by  the  surgeon  on  the  swelling  of  the 


OF  Tin-:   VEUTKBR.E.  299 

right  side  of  the  neck,  reduced  the  dislocation.  The  reduc- 
tion was  followed  by  a  restoration  of  impaired  functions. 

Mr.  Lawrence,  of  London,  says:  "The  possibility  of  the 
occurrence  of  complete  dislocations  of  the  vertebrae  without 
fracture,  has  long  been  a  disputed  point  among  many  of  the 
first  surgical  writers.  Boyer  and  Sir  A.  Cooper  are  of  opinion 
that  such  an  accident  can  not  happen  ;  and  Delpech  asserts, 
without  qualification,  that  a  careful  examination  of  the  form 
and  situation  of  the  bones  must  convince  the  observer  that 
such  accidents  can  not  occur.  The  case  of  Charles  Butcher, 
who  slipped  on  some  steps,  while  carrying  a  heavy  load  on  his 
head,  in  the  end  proved  that  a  vertebral  luxation  can  occur. 
The  accident  was  followed  by  complete  insensibility,  and  loss 
of  voluntary  motion  below  the  neck.  Functions  of  the  brain 
not  disturbed;  respiration  apparently  performed  merely  by 
the  diaphragm;  pulse  weak  and  slow;  body  cold;  penis  in  a 
state  of  erection.  No  irregularity  of  the  spinous  processes  <•<•>«!< I 
hi'  ulitt'i-rc.!/"  Death  took  place  in  four  days  after  the  reception 
of  the  injury.  The  autopsy  revealed  a  luxation  between  the 
fourth  and  fifth  cervical  vertebra:  "After  cutting  away  the 
muscles  from  the  back  of  the  spine,  the  cartilaginous  surfaces 
of  the  superior  articular  processes  of  the  fifth  cervical  vertebra 
came  into  view  ;  they  were  exposed  in  consequence  of  the  in- 
ferior processes  of  the  fourth  vertebra  having  been  completely 
dislocated  fnnrarth,  and  remaining  fixed  in  their  unnatural 
position.  The  yellow  ligaments  connecting  the  laminae  of  the 
two  vertebrae  were  torn  through,  and  the  bifid  apex  of  the 
fourth  spinous  process,  lay  in  close  contact  with  the  basis  of 
the  fifth.  On  the  front  of  the  column  an  unusual  projection 
was  observed,  but  the  anterior  longitudinal  ligamentous  ex- 
pansion was  entire.  The  body  of  the  fourth  was  completely  de- 
tached from  that  of  the  f  ft h  vertebra,  the  connecting  fibro  cartilage 
being  torn  through,  and  the  body  of  the  former  projected  by  its 
it-hole  depth  in  front  of  the  /.<//./•/' 

M.  Roberts,  of  Paris,  reports  the  case  of  a  carpenter  who 
in  attempting  to  raise  a  heavy  scaffolding  pole  and  at  a  certain 
point  being  unable  to  sustain  it  any  longer,  received  its  weight 
upon  his  back.  The  accident  was  immediately  followed  by 
complete  paralysis  below  the  point  injured.  Ts"o  projection  or 
irregularity  could  he  discovered  at  the  seat  of  the  lesion  ; 
death  occurred  on  the  eleventh  dav.  Dissection  showed  that 


•300  DISLOCATIONS. 

the  fifth  was  separated  from  the  sixth  dorsal  vertebra,  the  lat- 
ter being  driven  inwards  so  as  to  encroach  upon  the  medias- 
tinal  space.  The  ligaments  were  torn,  and  the  articular  sur- 
faces separated,  between  the  two  bones.  There  was  no  frac- 
ture of  any  process;  and  the  displacement  was  sufficient  to 
compress  the  spinal  cord. 

There  are  several  cases  of  dislocation  of  the  last  dorsal  on 
the  first  lumbar  vertebra  reported,  but  some  of  them  will  not 
admit  of  full  credence.  The  case  referred  to  in  Schmucher's 
surgical  work,  is  one  of  this  class. 

The  New  York  Journal  of  Medicine  for  1852,  contains  the 
account  of  a  case  of  dislocation  and  fracture  of  the  dorsal 
vertebrae,  which  occurred  in  the  practice  of  Dr.  Graves,  of 
New  Hampshire.  The  injury  was  produced  by  the  fall  of  a 
door,  the  man  being  under  it  in  a  stooping  posture.  The 
lower  extremities  were  immediately  paralyzed,  and  priapism 
took  place,  lasting  several  hours.  At  the  seat  of  the  injury, 
which  was  at  the  junction  of  the  lumbar  and  dorsal  vertebne, 
there  was  a  marked  appearance  of  displacement  of  the  parts, 
which  seemed  to  arise  from  a  fracture  and  dislocation,  or  a 
sliding  of  the  body  of  one  vertebra  over  another.  The  sur- 
geon placed  the  patient  on  his  belly,  and  fastened  a  folded 
sheet  under  his  arms  and  another  above  his  hips  :  chloroform 
having  been  administered,  extending  and  counter-extending 
forces  were  applied  by  means  of  the  sheets,  and  the  displaced 
vertebrae  were  reduced.  Paralysis  continued  until  the  six- 
teenth day,  when  slight  sensation  returned  to  the  feet :  during 
this  time  the  urine  had  to  be  discharged  by  the  daily  employ- 
ment of  a  catheter ;  and  the  bowels  were  occasionally  moved 
by  the  assistance  of  enemas.  In  six  or  eight  weeks  the  patient 
recovered  the  use  of  his  limbs;  and  the  normal  evacuations 
took  place  without  artificial  aid.  Galvanism  was  employed 
for  several  months  ;  and  ultimately  the  recovery  was  complete, 
though  a  prominence  remained  at  the  seat  of  injury. 

The  only  suspicious  circumstance  about  this  case  is  that  the 
falling  door  is  reported  to  have  struck  the  man  "  across  the 
shoulders,"  and  the  dislocation  is  claimed  to  have  been  "at 
the  junction  of  the  lumbar  and  dorsal  vertebne."  Perhaps  a- 
mistake  crept  into  the  report,  as  it  was  not  made  directly  to 
the  Journal  by  Dr.  Graves,  but  came  through  the  hands  of 
Prof.  Willard  Parker,  of  New  York.  The  case  terminated 


OF  THE  VERTEBRA.  301 

much  more  fortunately  than  similar  injuries  generally  do,  but 
this  circumstance  need  not  necessarily  cast  suspicion  upon  its 
authenticity. 

Death  has  occurred  from  attempts  to  effect  reduction  in 
a  of  vertebral  luxations.  There  would  evidently  be  more 
danger  existing  in  cases  complicated  with  fracture,  for  the 
fragments  might  be  forced  against  the  cord  and  do  irreparable 
mischief.  Dupuytren  expresses  a  caution  in  regard  to  the 
treatment  of  spinal  dislocations  in  the  following  language : 
"  the  reduction  of  these  dislocations  is  very  dangerous,  and  we 
have  often  known  an  individual  to  perish  from  the  compres- 
sion or  elongation  of  the  spinal  cord  which  always  attends 
these  attempts." 

I>r.  Ayres,  of  Brooklyn,  X.  Y.,  reports  in  the  Xew  York 
Journal  of  Medicine,  for  January,  1857,  a  case  of  dislocation 
occurring  between  the  cervical  vertebrae  from  some  unknown 
cause,  as  the  man  was  drunk  at  the  time  he  received  the  in- 
jury. The  neck  was  rigid  and  exhibited  a  peculiar  deformity 
which  could  not  attend  any  lesion  except  luxation  of  one  or 
more  of  the  cervical  vertebra.  There  was  no  paralysis;  but 
intense  pain  attended  the  displacement.  Great  difficulty  was 
experienced  in  attempts  to  drink  or  swallow  food.  The 
(.esophagus  and  larynx  seemed  to  be  pressed  upon  by  the 
bulging  forwards  of  several  of  the  cervical  vertebrae.  The 
back  of  the  neck  was  rendered  excessively  concave  and  the 
integument  was  thrown  into  folds  as  it  is  when  the  back  of 
the  head  is  forced  back  against  the  shoulders ;  the  front  of 
the  neck  presented  a  corresponding  convexity.  Between  the 
spinous  processes  of  the  fifth  and  sixth  cervu-al  vertebrae,  a 
marked  depression  could  be  felt,  and  this  was  the  point  at 
which  the  greatest  distress  was  felt  by  the  patient.  Dr. 
Ayres,  with  several  surgical  assistants  who  concurred  with 
him  in  the. diagnosis,  performed  a  successful  reduction  while 
the  patient  was  under  the  influence  of  chloroform.  Exten- 
sion was  applied  to  the  head  and  counter-extension  to  the 
shoulders,  and  while  the  head  was  rotated  and  pressure  made 
upon  prominent  points  in  the  neck,  the  displaced  bones  re- 
turned to  position,  arid  the  head  and  neck  resumed  their  nat- 
ural attitude  and  aspect.  The  difficulty  of  swallowing  and 
expectorating  soon  passed  off,  and  no  lasting  ill  consequences 
followed  the  luxation  or  the  reduction.  This  with  several 


302  DISLOCATIONS. 

other  equally  successful  attempts  at  reducing  dislocated  verte- 
brae, shows  that  in  all  favorable  cases,  well  directed  efforts 
.should  be  made  to  overcome  the  displacement. 

The  execution  of  criminals  by  hanging  was  designed  to 
bring  about  death  by  dislocation  and  not  by  strangulation,  as 
is  often  the  case.  If  death  takes  place  suddenly  the  trans- 
verse ligament  of  the  atlas  gives  way,  and  the  odontoid  pro- 
cess of  the  axis  becomes  free  to  impinge  upon  the  cord  at  a 
vital  point  Besides  the  rupture  of  the  transverse  ligament 
and  the  odontoid  displacement,  the  posterior  atlo-axoidean 
ligament  may  be  torn,  permitting  a  separation  of  the  atlas 
from  the  axis. 

The  playful  but  dangerous  practice  of  raising  a  child  by 
the  ears,  and  asking  it  to  "see  London,"  has  been  attended 
with  dislocation  at  the  atlo-axoidean  articulation  and  sudden 
death. 

The  dreadful  and  prolonged  sufferings  which  follow  disloca- 
tions of  the  vertebrae,  are  among  the  worst  that  can  be  in- 
flicted upon  the  human  body.  All  the  complex  horrors  of 
paralysis  are  liable  to  follow  these  luxations,  such  as  bed 
sores,  artificial  evacuations  of  the  bladder  and  rectum,  utter 
dependence  upon  others  to  have  even  necessary  wants  sup- 
plied, and  the  perversions  of  the  secretions  to  an  extent  that 
renders  every  phase  of  life  disagreeable,  and  death  welcome. 

In  a  dislocation  of  the  last  dorsal  vertebra,  which  occurred 
in  a  laborer  engaged  upon  the  government  buildings  in  this 
citv,  no  reduction  could  be  effected,  and  the  patient  lived 
twenty-seven  days.  The  man  did  not  suffer  excruciatingly 
from  the  first,  but  was  unable  to  move  the  pelvis  and  legs. 
lie  rode- home  and  talked  cheerfully  all  the  way.  lie  could 
not.  believe  he  was  seriously  or  dangerously  hurt,  and  won- 
dered why  he  could  not  move  his  legs.  The  urine  was  drawn 
with  a  catheter  for  ten  days,  and  then  it  began  to  dribble,  and 
flowed  incontinently  till  death.  The  bowels  were  evacuated 
by  means  of  enemas,  except  when  profuse  liquid  discharges 
•  •sniped  involuntarily.  Bed-sores  formed  upon  the  hips,  and 
at  Irnu'th  the  Hesh  on  the  legs  became  gangrenous  in  spots. 
Death  occurred  from  exhaustion  and  septica'inia.  An  autopsy 
revealed  the  dislocation  and  a  partial  fracture  of  an  articular 
process  of  the  vertebra  above  the  one  displaced.  The  cauda 
equina  was  pinched  by  the  dislocated  bones. 


CHAPTER    IV. 
DISLOCATION    OF    THE    RIBS 


The  ribs  do  not  properly  articulate  with  the  sternum,  there- 
fore they  can  only  be  dislocated  at  their  vertebral  extremities. 
The  separation  of  a  rib  from  its  cartilage,  or  of  its  cartilage 
from  the  sternum,  ought  to  be  regarded  as  a  fracture  and  not 
as  a  dislocation.  That  condition  of  tlie  chest  ordinarily  known 
as  "  chicken  breast,"  depends  upon  a  bending  of  the  carti- 
lages, and  is  not  a  luxation  in  the  true  interpretation  of  that 
word. 

The  heads  of  the  ribs  have  firm  connections  with  the  bodies 
of  the  vertebrae,  and  their  tubercles  articulate  with  the  trans- 
verse processes  of  the  dorsal  chain,  rendering  their  displace- 
ment exceedingly  difficult  and  necessarily  rare.  The  lower 
ribs,  embracing  the  false  and  floating,  having  less  support,  are 
the  most  frequently  dislocated. 

The  displacement  is  necessarily  inwards,  though  the  force 
producing  the  dislocation  may  carry  the  rib  above  or  below 
its  normal  position.  The  accident,  when  it  occurs,  is  pro- 
duced by  direct  violence,  such  as  kicks  and  blows ;  and  it 
would  be  extremely  difficult  to  determine  whether  a  fracture 
or  luxation  was  the  result.  Depression,  mobility,  and  pain, 
would  be  characteristic  of  either  lesion.  Crepitus  would  be 
indicative  of  fracture,  yet  one  rib  might  be  dislocated,  and 
another  broken.  The  fracture  of  a  spinous  or  transverse  pro-, 
cess  might  furnish  the  crepitation,  and  lead  to  the  conclusion 
that  the  injury  did  not  involve  dislocation.  Last  year  I  had 
an  opportunity  to  examine  the  body  of  a  man  who  died  from 
kicks  received  while  he  was  lying  upon  the  ground.  Several 
ribs  were  broken,  some  of  them  in  two  places,  and  the  tenth 
and  eleventh,  on  the  left  side,  were  dislocated. 

Brausby  Cooper  reports  the  following  case  of  a  luxated  rib  : 
"  Mr.  Webster,  surgeon  at  St.  Albans,  when  examining  the 

(303) 


304  DISLOCATIONS. 

body  of  a  patient  who  had  died  of  fever,  found  the  head  of 
the  seventh  rib  thrown  upon  the  front  of  the  corresponding- 
vertebra,  and  there  anchylosed.  Upon  inquiry,  Mr.  \Vebster 
learned  that  this  gentleman,  several  years  before,  had  been 
thrown  from  his  horse  across  a  gate,  for  which  accident  he 
had  been  subjected  to  the  treatment  usually  followed  in  frac- 
tures of  the  ribs,  and  there  is  every  reason  to  believe  that  it 
was  at  this  time  that  the  dislocation  occurred." 

Other  dislocations  of  the  kind  may  occasionally  occur,  but 
as  there  is  no  opportunity  to  verify  the  diagnosis  until  after 
the  death  of  the  patient,  they  remain  undiscovered.  And 
even  if  they  were  discovered,  it  would  be  a  difficult  matter  to 
restore  a  displaced  rib  to  its  natural  position.  A  bandage 
might  be  applied  to  the  chest  to  restrain  the  costal  movements 
and  compel  the  patient  to  breathe  mostly  by  the  action  of  the 
diaphragm ;  and  the  region  of  the  injury  might  be  subjected 
to  the  influence  of  chloroform  and  aconite,  or  the  subcutane- 
ous action  of  morphia,  and  anodynes  might  be  administered 
internally,  but  all  this  would  be  appropriate  in  fracture  of  the 
rib,  hence  there  is  no  necessity  for  a  differential  diagnosis  be- 
tween the  two  injuries,  as  nothing  would  be  gained  by  the 
discrimination.  A  patient,  therefore,  need  not  be  subjected 
to  distressing  and  perhaps  dangerous  examinations  to  deter- 
mine whether  fracture  or  dislocation  of  one  or  more  ribs  ex- 
isted. To  be  convinced  that  the  one  or  the  other  lesion  liad 
been  received,  is  practically  sufficient  for  the  surgeon.  There 
being  several  authenticated  cases  of  costo-vertebral  disloca- 
tions, a  question  on  that  point  no  longer  exists  :  and  the  injury 
being  necessarily  serious  the  prognosis  should  be  always 
guarded.  In  simple  dislocation  or  fracture  of  the  rib,  with- 
out much  injury  to  the  thoracic  viscera,  a  recovery  may  be 
expected ;  but  with  several  ribs  broken  or  dislocated,  the  re- 
sult is  problematical.  A  force  which  breaks  or  luxates  sev- 
eral ribs  is  about  sure  to  extend  to  the  organs  within,  and  in- 
flict dangerous  lesions  upon  them. 


CHAPTER  V. 
DISLOCATION  OF  THE  CLAVICLE. 


The  firm  ligamentous  connections  of  the  clavicle  to  the 
sternum  and  the  scapula  give  forces  a  better  opportunity  to 
break  the  bone  than  to  dislocate  it.  The  acromial  extremity 
of  the  clavicle  is  the  most  completely  covered  with  soft  tis- 
sues ;  and  in  addition  to  the  acromio-elavietilar  ligaments, 
\vhich  form  a  capsule  for  the  joint,  the  coraco-clavicular  fas- 
ciculus of  ligamentous  fibres  holds  the  i-lavicle  in  firm  connec- 
tion with  the  scapula.  This  strong  articulation  would  seem- 
ingly id-event  luxation,  yet  the  joint  sutlers  such  a  lesion 
more  IVe([iH'iitiy  than  the  sterno-clavicular  articulation.  Of 
twenty-three  dislocations  of  the  clavicle  observed  by  Hamilton, 
five  were  at  the  sternal  end  and  eighteen  at  the  acromial 
(.•«-<ij>ii/tt-r  dislocations).  The  movements  at  the  articular  ex- 
tremities of  the  clavicle  are  of  a  gliding  character  and  quite 
limited  in  range,  so  that  it  is  impossible  for  the  articular  sur- 
faces to  undergo  much  change  in  their  relation  to  each  other, 
or  that  any  of  the  ligaments  can  be  put  greatly  on  the  stretch. 
Ceteris  paribus,  the  greater  the  extent  of  motion  in  a  joint, 
the  greater  the  liability  to  dislocation. 

The  sternal  end  of  the  clavicle  may  be  dislocated  forwards, 
backwards,  and  upwards.  The  cartilage  of  the  first  rib  pre- 
vents displacement  downwards.  The  forward  dislocation  is 
the  most  frequent,  and  may  be  partial  or  complete.  In  the 
latter,  the  head  of  the  bone,  besides  projecting  forwards,  is 
depressed  below  its  natural  level ;  in  the  incomplete,  it  is 
usually  slightly  raised. 

Luxation  of  the  sternal  end  of  the  clavicle  is  generally  pro- 
duced by  a  fall  upon  the  point  of  the  shoulder,  the  force  driv- 
ing the  bone  inwards  or  forwards.     It  is  probable  that  the 
shoulder  is  carried  a  little  backwards  as  well  as  inwards,  or 
20  (305) 


306  DISLOCATIONS. 

the  head  of  the  clavicle  would  not  slide  out  of  its  place,  but 
break  somewhere  in  its  course.  The  nature  and  direction  of 
the  forces  which  produce  dislocations  of  the  clavicle  are  not 
always  understood.  Quite  contrary  causes  have  been  alleged 
as  producing  these  displacements. 

SYMPTOMS. — The  prominent  head  of  the  clavicle  seen  and  . 
felt  in  its  abnormal  situation,  covered  only  by  the  integument, 
leaves  no  doubt  as  to  the  nature  of  the  injury.  Where  the 
head  of  the  bone  should  be  there  is  a  depression  into  which 
the  linger  may  be  thrust.  The  corresponding  shoulder  still 
holds  its  position  a  little  back  where  it  has  been  driven  ;  the 
movements  of  the  arm  are  restricted;  and  great  pain  is  felt 
at  the  point  of  displacement.  The  sterno-cleido-mastoid 
muscle  in  the  lower  part  of  its  course,  is  rendered  salient ; 
and  the  tension  of  the  muscle  draws  the  head  slightly  down- 
wards and  to  one  side,  as  in  "  wry-neck." 

Movements  imparted  to  the  shoulder  sensibly  atiect  the  dis- 
placed head  of  the  bone ;  raising  the  shoulder  depresses  the 
head  of  the  clavicle,  and  depression  of  the  shoulder  elevates. 
it ;  if  the  shoulder  be  forcibly  carried  backwards,  the  head 
of  the  clavicle  drops  into  place,  or  is  brought  to  a  point  favor- 
able to  reduction. 

A  fracture  near  the  sternal  end  of  the  clavicle  may  exhibit 
deformities  similar  in  appearance  to  dislocation  of  the  head 
of  the  bone:  and  I  have  seen  syphilitic  enlargements,  and 
periosteal  tumors  which  closely  resembled  a  luxation. 

The  displacement,  if  considerable  or  complete,  has  not  oc- 
curred without  laceration  of  the  anterior  and  posterior  sterno- 
clavicular  ligaments,  and  the  rhomboid  could  hardly  escape 
being  torn.  The  inter-articular  cartilage  may  remain  in  con- 
nection with  the  sternum  or  follow  the  head  of  the  clavicle. 

TREATMENT. — It  is  not  a  difficult  matter  to  bring  the  head 
of  a  dislocated  clavicle  to  the  point  of  reduction,  by  drawing 
the  shoulder  outwards  and  backwards,  the  surgeon's  knee 
being  placed  between  the  scapulae  of  the  patient ;  but  to  press 
it  completely  into  place  and  keep  it  there,  quite  baffles  the 
best  skill.  The  great  disposition  of  the  bone  to  slip  out  of 
place  when  successfully  reduced,  has  led  to  the  invention  of 
many  methods  intended  to  keep  it  in  its  normal  position.  In 
most  instances,  no  kind  of  retaining  apparatus  yet  devised. 


OF  THE  CLAVICLE.  307 

Avill  effectually  retain  the  bone  in  position.  In  most  cases  the 
reduction  can  not  be  accomplished,  and  in  the  few  in  which 
the  bone  is  replaced,  the  luxation  has  again  occurred  in  a  few 
minutes,  or  a  few  days  at  most.  Fortunately  the  utility  of 
the  limb  is  not  substantially  impaired,  even  if  the  bone  con- 
tinues unreduced. 

The  dressing  ordinarily  used  for  fracture  of  the  clavicle  is 
as  useful  us  any  to  retain  the  head  of  the  bone  in  place,  and 
as  a  protection  against  a  recurrence  of  the  luxation.  The 
shoulder  is  to  be  carried  outwards  and  backwards,  and  kept 
fixed  in  that  position.  Sir  Astley  Cooper  recommended  an 
apparatus  something  like  a  common  shoulder  brace  to  carry 
out  the  indications.  A  pad  in  the  axilla  and  a  sling  to  support 
and  steady  the  arm,  constitute  a  serviceable  appliance.  A 
thoracic  bandage,  with  a  pad  in  the  arm-pit  as  a  fulcrum  over 
which  the  arm  acts  as  a  lever  to  pry  the  shoulder  outwards, 
has  been  employed  with  success.  Velpeau  bandaged  the  arm 
to  the  side,  with  the  hand  carried  to  the  opposite  shoulder. 
Xelaton  recommended  that  pressure  be  kept  upon  the  head 
of  the  replaced  bone,  and  used  a  truss  for  that  purpose,  the 
pad  being  placed  over  the  articulation  and  the  spring  passing 
under  the  axilla  of  the  sound  side.  The  dressing  is  to  be 
worn  and  the  pressure  kept  up  for  six  weeks  or  two  months. 

Luxation  of  the  Sternal  End  of  the  Clavicle  Upwards. — This 
accident  has  only  recently  acquired  an  established  place  in  sur- 
gical pathology  ;  the  older  surgeons  doubted  the  possibility  of 
its  occurrence.  Malgaigne  has  collected  five  examples ;  and  the 
Buffalo  Medical  Journal  contains  an  account  of  another  that 
happened  in  the  practice  of  Dr.  Rochester.  They  were  all 
occasioned  by  a  violent  force  that  carried  the  shoulder  down- 
wards and  inwards.  The  patient  of  Dr.  Rochester  was  caught 
under  the  bar  of  a  gateway  while  seated  upon  a  load  of  wood, 
and  had  the  shoulder  forced  downwards  and  a  little  back- 
wards. The  sternal  extremity  of  the  clavicle  was  driven  up- 
wards in  the  direction  of  the  chin,  until  it  rested  on  the  thy- 
roid cartilage,  the  displacement  being  followed  by  difficulty  of 
breathing  and  loss  of  speech.  The  reduction  was  easily  ef- 
fected, but  no  kind  of  apparatus  would  retain  the  bone  per- 
fectly in  place.  The  head  of  the  bone  always  remained  a 
little  above  and  a  half  inch  in  front  of  its  natural  position, 
though  the  arm  retained  its  usefulness. 


308  DISLOCATIONS. 

The  symptoms  of  this  rare  dislocation  are  very  marked, 
the  head  of  the  bone  being  felt  above  the  upper  border  of  the 
sternum,  and  near  the  median  line  of  the  neck  ;  a  depression 
can  be  felt  where  the  head  of  the  bone  belongs,  and  the  space 
between  the  first  rib  and  clavicle  is  increased.  There  is  prob- 
ably complete  rupture  of  all  the  ligaments  of  the  joint,  as  well 
as  of  the  costo-clavicular.  The  reduction  is  readily  effected 
by  lifting  the  shoulder  upwards,  and  carrying  it  outwards, 
the  head  of  the  bone  at  the  same  time  being  pressed  down 
into  position.  Retention  is  difficult,  if  not  impossible.  In 
none  of  the  cases  yet  reported  has  there  been  one  of  success- 
ful retention,  though  the  displacement  did  not  seriously  impair 
the  functions  of  the  arm.  The  treatment  after  reduction  con- 
sists in  the  use  of  such  appliances  as  shall  steadily  retain  the 
shoulder  upward  and  outward.  A  pad  in  the  axilla,  and  a 
sling  to  keep  the  elbow  to  the  chest,  with  the  hand  drawn  up 
towards  the  opposite  shoulder,  are  the  simplest  and  most  ef- 
fective means  at  command.  It  is  difficult  to  maintain  con- 
tinued pressure  downwards  upon  the  head  of  the  bone. 

Dislocation  of  the  Sternal  End  of  the  Clavicle  Backwards. —  A 
combination  of  forces,  as  in  accidents  of  a  crushing  character, 
may  displace  the  sternal  end  of  the  clavicle  backwards,  com- 
pelling the  head  of  the  bone  to  take  a  position  behind  its 
normal  location.  This  dislocation  is  rare,  yet  several  cases 
have  been  reported.  If  a  force  drive  the  clavicle  inwards  at 
the  same  time  the  backward  luxation  occurs,  the  head  of  the 
bone  may  press  disagreeably  and  even  dangerously  upon  the 
trachea  and  oesophagus. 

The  Medical  Times  and  Gazette  contains  the  account  of  a 
case  which  occurred  in  the  practice  of  Dr.  Morgan,  at  the 
Middlesex  Hospital,  in  1852.  "  A  girl,  ten  years  of  age,  was 
knocked  down  by  a  carriage,  and  appears  to  have  been  trod- 
den on  by  one  of  the  horses.  On  admission,  she  suffered 
much  from  dyspnoea,  the  head  was  inclined  forwards  and  could 
not  be  raised  without  extreme  pain.  There  were  marks  of 
bruising  over  the  right  shoulder  and  clavicle.  Where  the 
head  of  the  bone  should  be,  there  was  a  depression  into  which 
the  fingers  might  be  thrust,  and  the  articular  surface  of  the 
sternum  could  be  distinctly  felt,  while  the  head  of  the  clavicle 
was  evidently  behind  it. 


OF  THE  CLAVICLE. 

"  On  placing  thu  knee  against  her  spine,  and  gently  drawing 
tlie  two  shoulders  backwards,  the  bone  was  easily  restored  tc 
its  proper  place,  causing  obvious  relief  to  the  dyspnoea  ;  but 
immediately  on  leaving  hold  of  the  shoulders,  the  bone  fell 
back,  and  the  dyspnoea  returned.  A  splint  was  then  placed 
across  the  shoulders,  with  a  pad  between  it  and  the  spine,  the 
shoulders  being  drawn  to  the  splint  by  a  bandage ;  by  these 
means  the  bone  was  kept  firmly  in  its  place,  pillows  being  so 
arranged  along  the  patient's  back  that  the  splint  should  not 
feel  uncomfortable.  On  the  apparatus  being  fixed,  she  could 
lean  her  head  backwards,  and  stated  that  her  pain  was  much 
relieved.  The  splint  was  kept  on  for  a  fortnight ;  the  bone 
then  being  quite  steady  in  its  place.  She  was  allowed  to  re- 
main in  bed  without  any  bandage.  The  articulation  became 
in  four  weeks  quite  as  firm  as  that  on  the  other  side  ;  and  the 
arm  could  be  moved  without  causing  any  pain."  This  report 
gives  the  cause  of  the  dislocation,  depicts  the  prominent 
symptoms,  and  offers  a  plan  of  treatment  which  proved  suc- 
cessful, at  least  in  that  one  instance.  Other  cases  are  reported 
which  throw  no  additional  light  upon  the  character  of  the  in- 
jury or  its  surgical  management.  In  one  or  two  instances  in 
which  reduction  was  never  accomplished,  the  functions  of  the 
arm,  were  not  seriously  impaired. 

If  an  attempt  be  made  to  save  a  leg  that  has  suffered  com- 
pound dislocation  of  the  knee,  let  there  be  free  discharge 
from  the  wound,  and  perfect  rest.  Evaporating  lotions  would 
keep  the  injured  parts  cool,  yet  warm  wet  cloths  would  do 
best  to  keep  off  tetanus  and  some  other  dangerous  complica- 
tions. The  danger  comes  from  shock,  suppuration,  tetanus, 
and  gangrene.  The  swelling  is  usually  great  and  the  pain 
fearful.  Then  it  is  to  be  considered  that  a  patient  with  an 
open  injury  to  the  knee  may  seemingly  do  well  for  a  few 
days,  and  then  sink  and  die  without  apparent  cause  for  the 
sudden  change  for  the  worse. 


CHAPTER    VI. 
DISLOCATION  OF   THE  SCAPULA. 


Dislocations  of  the  &eaj9ufa-e£at»ettlar  articulations  have  gener- 
ally been  described  as  k>  luxations  of  the  acr<>,ni<il  end  of  flic 
clavicle,"1  but  in  order  to  establish  uniformity  in  our  nomen- 
clature, which  has  now  discarded  such  terms  as  "  dislocation 
of  the  radius  and  ulna  upon  the  carpus,"  "  dislocation  of  the 
tibia  at  the  ankle,"  etc.,  it  seems  necessary  to  consider  the 
acromion  process  of  the  scapula  as  dislocated  from  the  clavicle, 
the  latter  being  the  mere  fixed  point  and  nearest  to  the  trunk 
Use  will  make  this  naming  of  the  injuiy  seem  correct  when 
it  is  once  rendered  familiar.  Luxation  at  this  joint  is  more 
frequent  than  at  the  sterno-clavicular  articulation.  In  the 
great  majority  of  cases  the  acromion  is  forced  beneath  the 
outer  end  of  the  clavicle ;  in  rare  instances  the  acromion  is 
made  to  take  a  position  above  the  clavicle ;  and  in  extremely 
rare  accidents  the  displacement  is  carried  so  far  that  the  cora- 
coid  process,  as  well  as  the  acromion,  takes  a  higher  level  than 
the  clavicle. 

The  causes  of  the  injury  are  falls  upon  the  extremity  of  the 
shoulder,  and  kicks  and  blows  upon  the  same  point.  Direct 
violence,  applied  to  the  scapula,  generally  produces  the  lesion, 
though  if  the  shoulder  be  fixed,  and  a  force  come  from  the 
opposite  side  of  the  body  in  a  way  to  tilt  the  outer  end  of  the 
clavicle  upwards,  luxation  maybe  produced  by  an  indirect 
action. 

The  symptoms  of  dislocation  of  the  scapula  downwards, 
are  tolerably  well  marked  ;  the  acromion  is  overlapped  by  the 
clavicle  which  projects  sufficiently  to  be  distinctly  felt;  the 
pain  is  severe,  and  the  motions  of  the  arm  are  restrained : 
the  shoulder  appears  slightly  depressed,  and  the  arm  some- 
what lengthened,  the  deformity  partaking  few  of  the  features 
of  a  dislocation  of  the  humerns. 

(310) 


OF  THE  SCAPULA.  311 

In  complete  luxation  the  ligamentous  structures,  including 
the  coraeo-clavicular  ligament,  are  lacerated ;  and  the  soft 
parts  covering  the  articulation  may  be  bruised  and  torn.  If 
the  displacement  be  great  the  acromion  is  driven  inwards  be- 
neath the  clavicle  so  far  that  the  end  of  the  bone  forms  a 
prominence  immediately  under  the  skin  outside  the  acromion. 

TREATMENT. — By  drawing  the  shoulder  outwards  and  back- 
wards, and  pressing  upon  the  outer  end  of  the  clavicle,  the 
bones  can  easily  be  restored  to  their  natural  relations.  There 
is  always  great  difficulty  in  retaining  them  in  position,  owing 
to  the  narrowness  and  obliquity  of  the  articulating  surfaces, 
as  well  as  the  action  of  the  clavicular  portion  of  the  trapezius 
muscle.  However,  the  parts  implicated  in  the  displacement 
soon  adapt  themselves  to  their  new  relations,  and  the  utility 
of  the  arm  and  shoulder  is  but  little  impaired.  Notwith- 
standing the  difficulty  of  retaining  the  bones  in  their  natural 
relation,  success  has  occasionally  attended  a  well  directed  and 
prolonged  effort.  The  ordinary  dressing  for  fracture  of  the 
clavicle,  consisting  of  a  pad  in  the  axilla  and  a  sling  to  lift 
the  elbow  upwards  and  bring  it  inwards,  is  a  proper  retentive 
appliance.  A  thick  compress  placed  upon  the  outer  end  of 
the  clavicle,  and  bound  down  by  a  long  strip  of  adhesive  plas- 
ter reaching  from  the  lower  ribs  posteriorly  to  the  lower  end 
of  the  sternum  anteriorly,  prevents  a  recurrence  of  the  dis- 
placement, and  with  the  rest  of  the  dressing,  helps  to  keep 
the  articular  surfaces  steadily  in  apposition.  The  compress 
may  be  held  in  place  by  a  strip  of  adhesive  plaster  passed  over 
it  and  under  the  elbow  of  the  same  side.  A  short  strip  reach- 
ing from  the  compress  to  the  side  of  the  neck  will  prevent 
the  other  part  of  the  dressing  from  slipping  over  the  point  of 
the  shoulder.  Various  contrivances  have  been  devised  to 
keep  the  bones  in  their  relative  positions,  but  none  of  them 
have  universally  succeeded.  The  mobility  of  the  scapula  is 
the  greatest  obstacle  to  continued  adjustment.  Tourniquets 
have  been  recommended  to  retain  the  bones  in  apposition,  the 
strap  passing  under  the  elbow  and  the  pad  resting  on  the 
outer  end  of  the  clavicle.  Shoulder  straps  connected  with  a 
sling  a-t  a  point  where  the  elbow  rests,  have  been  employed  by 
various  surgeons,  but  with  all  the  modifications  ingenuity  has 
called  forth,  no  appliance  has  been  invented  which  will  satis- : 
fa«-torilv  fulfill  all  the  indications. 


312  DISLOCATIONS. 

Dislocation  of  the  Scapula  Upward. — What  lias  been  called 
"  infra-acromial "  dislocation  of  the  clavicle,  or  the  upward  dis- 
placement of  the  scapula  as  regards  the  acromial  extremity 
of  the  clavicle,  is  an  exceedingly  rare  accident.  Two  oppos- 
ing forces  acting  upon  the  clavicle  and  scapula,  the  one  de- 
pressing the  former,  and  the  other  elevating  the  latter  bone, 
might  produce  the  injury.  In  the  ease  reported  by  Tournel, 
the  patient  was  knocked  down  by  a  horse  and  trod  on.  In 
looking  at  the  articulated  skeleton  it  might  seem  that  the 
scapula  could  not  be  dislocated  upwards  without  at  the  same 
time  fracturing  the  coracoid  process,  yet  experiments  upon 
the  cadaver  show  that  the  shoulder-blade  may  be  rocked  out- 
wards sufficiently  to  permit  this  acromio-clavicular  displace- 
ment without  breaking  the  coracoid  process.  The  dislocation 
must  be  attended  with  rupture  of  the  acrornio-  and  coraco- 
clavicular  ligaments.  The  general  symptoms  will  be  those 
attending  ordinary  injuries  of  the  kind  ;  and  the  special  diag- 
nostic marks  will  be  as  follows:  the  acromion  stands  out 
prominently,  and  on  its  inside  a  depression  can  be  discovered 
with  the  fingers,  the  end  of  the  clavicle  being  below  the  articu- 
lar facette  on  the  acromion.  If  much  swelling  has  not  taken 
place,  the  positions  of  the  two  bones  can  be  accurately  deter- 
mined by  careful  manipulation. 

TREATMENT.  —  Reduction  is  accomplished  by  drawing  the 
shoulder  outwards,  and  rocking  the  scapula  gently  to  disen- 
gage the  acromiou  from  the  end  of  the  clavicle.  These 
manoeuvres  are  sufficient  to  bring  the  articular  surfaces  of  the 
two  bones  into  apposition.  This  form  of  acromio-clavicular 
dislocation,  when  once  reduced,  is  not  so  troublesome  as  the 
other  more  common  variety.  The  return  of  the  scapula  to  its 
natural  position  presents  the  coracoid  process  as  an  obstacle 
to  the  descent  of  the  clavicle.  After  reduction  is  accom- 
plished, it  is  only  necessary  to  secure  the  arm  to  the  side  of 
the  thorax  and  prevent  all  motion  at  the  shoulder  for  two  or 
three  weeks.  A  handkerchief  extending  under  the  arm  of 
the  injured  side  and  tied  across  the  neck  on  the  sound  side, 
will  hold  the  scapula  snugly  to  the  thorax  and  prevent  that 
tilting  of  the  bone  which  favors  the  acromio-clavicular  dis- 
placement. 

Dislocation  of  the  scapula  upward  and  backward,  so  as  to 
throw  the  coracoid  process  above  the  clavicle,  is  an  accident 


OF  THE  SCAPULA.  313 

that  was  not  recognized  by  the  older  surgical  writers.  The 
lesion  is  now  generally  called  the  infra -coracoid  dislocation  of 
the  clavicle,  though  in  accordance  with  our  adopted  nomen- 
clature, as  well  as  in  /art,  it  is  a  scapular  displacement.  The 
pathology  of  this  accident  is  not  well  understood,  at  least  it 
has  not  been  well  describe*!  ;  and  the  cause  of  the  injury  is 
decidedly  problematical.  The  force  must  be  of  a  character 
to  rotate  the  scapula  and  wrench  it  from  its  connections  with 
the  clavicle.  In  reality,  the  injury  must  be  an  exaggerated 
form  of  the  upward  dislocation  of  the  scapula,  that  bone  being 
forced  outwards  and  upwards  to  a  degree  which  throws  the 
coracoid  process  above  the  clavicle,  the  latter  bone  being 
made  to  take  a  position  in  the  axilla.  Such  a  peculiar  injury 
must  be  exceedingly  rare;  and  it  is  not  strange  that  its  ex- 
istence should  be  doubted.  However,  the  most  unaccountable 
accidents  will  occasionally  occur  to  astonish  the  incredulous, 
and  this  may  be  one  of  them.  It  is  easier  to  see  how  the 
bones  can  take  that  unusual  position,  than  to  understand  the 
complex  nature  of  the  forces  necessary  to  effect  the  displace- 
ment. 

If  I  were  called  to  treat  such  an  injury  I  should  attempt  to 
reduce  the  dislocation  by  placing  the  knee  in  the  armpit,  and 
using  the  arm  as  a  lever  to  bring  the  scapula  back  into  place ; 
the  upward  pressure  of  the  knee  would  tend  to  dislodge  the 
clavicle  from,  the  axilla  and  direct  it  back  into  place  ;  while 
the  scapula  could  be  made  to  rotate  in  any  direction  by  move- 
ments imparted  to  the  arm. 


CHAPTER  VII. 
DISLOCATION    OF   THE    HUMERUS 


Dislocation  of  the  shoulder  is  so  common  au  occurrence 
that  it  is  deserving  of  unusual  attention.  A  practitioner  of 
medicine  and  surgery  will  not  pursue  an  active  part  in  his  pro- 
fession for  many  years  without  being  called  upon  to  take 
charge  of  a  shoulder  luxation  ;  though  he  may  never  encoun- 
ter in  a  long  career  of  practice,  one-half  the  different  disloca- 
tions described  in  his  text  bo6ks. 

The  humerus  is  dislocated,  according  to  the  tables  of  Mal- 
gaigne  and  several  other  authors,  more  frequently  than  all  the 
other  bones  of  the  body  together.  This  fact  in  itself  is  suffi- 
cient to  demand  for  the  subject  the  most  profound  considera- 
tion. 

The  peculiar  structure  of  the  shoulder-joint,  the  shallowness 
of  its  socket,  the  large  size  and  globular  form  of  the  head  of 
the  humerus,  the  extensive  movements  and  long  leverage  af- 
forded by  the  arm,  and  its  frequent  exposure  to  injury  in  pro- 
tecting the  more  important  central  organs  of  the  body,  aiv  all 
circumstances  which  contribute  to  the  facility  and  frequency 
of  dislocation.  On  the  contrary,  the  great  mobility  of  the 
scapula,  and  the  flexibility  of  the  spinal  column,  which  serve 
to  transmit  and  decompose  forces,  operate  as  counter-balanc- 
ing influences. 

Age  exerts  a  marked  influence  upon  dislocations  of  the 
shoulder,  the  accident  being  extremely  rare  during  childhood 
and  old  age,  though  I  have  met  with  an  example  in  a  c-liild 
under  a  year  old,  and  another  in  a  woman  over  seventy.  Mr. 
Watts,  house-surgeon  to  Middlesex  Hospital,  treated  a  case 
of  dislocation  forwards  in  an  infant  fourteen  days  old.  The 
accident  most  frequently  occurs  in  adults  from  thirty  to  sixty 
years  of  age. 


OK  THK  HUMERUS.  315 

Strange  though  it  may  be,  the  pathology  of  this  common 
injury  is  still  imperfectly  understood.  Surgical  writers  of  the 
French  School,  in  seeking  for  distinctions  and  refinements, 
have  contributed  not  a  little  to  involve  the  subject  in  inextri- 
cable confusion.  The  student  is  apt  to  be  discouraged  when 
he  finds  his  author  has  described  eight  or  ten  different  forms 
of  luxation  peculiar  to  one  joint.  But,  when  he  finds  that: 
there  are  only  three  principal  displacements  of  the  humerus 
to  study,  and  that  all  other  forms  so  elaborately  described  by 
some  authors,  are  mere  variations  of  one  or  the  other  of  the 
three  kinds,  he  is  encouraged  to  enter  upon  the  study  of  them 
with  greater  zeal. 

The  old  method  of  describing  the  different  luxations  of  the 
shoulder  under  the  nomenclature  of  downwards,  forwards, 
backwards,  etc.,  often  led  to  confusion,  none  of  them  indicat- 
ing definitely  the  exact  position  of  the  head  of  the  humerus. 
Names  derived  from  the  position  the  head  of  the  bone  in  its 
new  situation  assumes  in  regard  to  certain  well  defined  points 
on  the  scapula,  are  more  concise,  definite,  and  expressive.  For 
instance,  the  "  backward"  dislocation  is  called  the  subspinous 
luxation  of  the  humerus,  the  word  in  Italics  indicating  that 
the  head  of  the  humerus  rests  beneath  the  spinous  process  of 
the  scapula  ;  the  "  downward  "  dislocation  is  designated  as  the 
siibglenoid,  meaning  that  the  head  of  the  humerus  is  thrown 
beneath  the  glenoid  socket;  and  the  "forward"  o'r  "  inward" 
dislocation,  takes  the  name  of  snbcoracoi<(,  to  show  that  the 
head  of  the  humerus  is  forced  beneath  the  coracoid  process. 
And  if  the  force  be  sufficient  in  any  case  to  curry  the  displaced 
bone  very  far  inwards  or  forwards,  so  it  shall  fall  inside  the 
coracoid  process  and  beneath  the  clavicle,  the  luxation  may 
be  called  intra-eoraeoid  or  subdavicidar,  to  indicate  definitely 
the  extent  of  the  displacement  and  the  position  the  head  of 
the  humerus  has  assumed.  This  is  a  modification  of  the  no- 
menclature adopted  by  Malgaigne  ;  and  it  is  hoped  that  the 
attempt  to  simplify  the  system  will  prove  advantageous  to  the 
beginner  in  the  study  of  this  otherwise  vexatiously  complex 
classification.  I  shall  commence  with  what  I  regard  as  the 
most  frequent  variety  of  luxations  of  the  humerus. 

Subcoracoiff. — This  is  what  the  older  writers  have  pronounced 
a  dislocation  forwards ;  and  as  a  form  or  variety  of  displace- 
ment, embraces  the  wtra-cor«c.oi<1  of  Malgaigne,  his  two  varie- 


P)16  DISLOCATIONS. 

ties  being  brought  under  one  head  from  the  fact  that  the  dif- 
ference between  them  is  rather  of  degree  than  of  kiwi.  If  the 
critical  reader  is  not  satisfied  with  this  manner  of  considering 
the  subject,  he  may  regard  the  terms  employed  as  expressing 
subvarieties  of  one  common  form. 

In  each  of  the  three  varieties  of  dislocation  the  head  of  the 
humerus  rests  against  the  rim  of  the  glenoid  fossa.  If  the 
displacing  force  drives  the  head  of  the  bone  far  inwards,  so  it 
shall  rest  inside  the  coracoid  process,  establishing  the  sulx-la.- 
rn-nlar  variety,  there  may  be  some  space  between  the  glenoid 
rim  and  the  humerus,  though  not  as  muc'h  as  mere  reasoning 
upon  the  subject  would  lead  us  to  suppose.  Dissections  of  the 
parts  involved  in  the  subclavieular  dislocation  show  that  rota- 
tions of  the  scapula  and  humerus  bring  the  two  bones  into 
pretty  intimate  relations.  If  the  teres  minor,  and  the  infra- 
and  snpra-spinatus  muscles  continue  untorn,  they  will  not 
permit  the  head  of  the  humerns  to  remain  at  a  distance  from 
the  glenoid  border  unless  some  obstacle  intervene.  Should 
the  head  of  the  humerus  be  forced  within  the  coracoid  pro- 
cess and  there  lodge  or  become  fixed,  the  dislocation  would 
be  truly  intra-coracoid,  but  such,  is  not  often  the  case. 

For  many  years  I  have  been  inclined  to  dissent  from  the 
commonly  accepted  opinion  in  regard  to  the  most  frequent 
form  of  dislocation  at  the  shoulder-joint.  I  critically  exam- 
ined every  case  coming  under  my  observation,  whether  in  the 
living  or  the  dead  subject.  I  frequently  met  with  the  sub- 
coracoid variety,  and  rarely  with  the  subglenoid  ("  down- 
ward"), though  many  of  the  lesions  I  Carefully  investigated 
and  found  to  be  subcoracoid,  had  been  pronounced  downward 
dislocations  by  surgeons  of  more  than  ordinary  experience 
and  ability.  At  length  1  was  gratified  while  looking  up  au- 
thorities on  this  subject,  to  find  that  Malgaigne  regarded  the 
subcoracoid  variety  as  happening  more  frequently  than  any 
other  form  of  shoulder  dislocation;  and  Mr.  Flower,  in  his 
surgical  contribution  to  Holmes'  System  of  NW/y/n-y.  says  :  "Of 
forty-one  specimens  of  dislocation  of  the  shoulder-joint,  pre- 
served in  the  different  anatomical  museums  in  London,  as 
many  as  thirty-one  undoubtedly  belong  to  this  form;  and  of 
fifty  recent  cases  which  have  come  under  the  observation  of 
myself,  or  gentlemen  in  whom  [  can  place  perfect  confidence, 
and  of  which  I  have  full  particulars,  in  forty-four  the  head  of 


OF    THE    HUMERUS. 


317 


the  humerus  was  placed  so  closely  beneath  the  coracoid  pro- 
cess as  to  justify  the  appellation  of  '  subcoracoid.'  In  the  face 
of  these  facts,  it  is  difficult  to  understand  how  the  wide-spread 


FIG.  108. 


error  of  regarding  the  subglenoid  as  the 
typical  form  of  dislocation  at  the  shoul- 
der-joint, should  have  been  so  long  main- 
tained. A  simple  process  of  reasoning 
upon  the  anatomical  structure  of  the 
part  would  suffice  to  show  that,  when- 
ever the  humerus  is  thrown  from  its 
•socket,  it  will  almost  of  necessity  be 
drawn  upwards  until  it  is  arrested  either 
by  the  coracoid  process  in  front,  or  the 
spine  or  acromion  behind.  Even  in  the 
dead  subject,  when  dislocation  is  arti- 
ficially produced  by  forcibly  elevating  the 
arm,  while  the  scapula  is  fixed,  the 
humerus  is  almost  always  drawn  up  close 
against  the  under  surface  of  the  coracoid 
process;  a  fortiori,  in  the  living,  must 
the  action  of  the  deltoid,  coraco-brachi- 
alis,  and  biceps  cause  it  to  assume  this 
position.  The  truth  is,  that  nearly  all 

the  cases  of  '  dislocation  into  the  axilla,'  or  '  downwards,' 
described  as  so  common  by  Sir  A.  Cooper,  and  all  subsequent 
authors,  have  really  been  examples  of  this  variety,  to  which 
the  anatomical  characters  of  the  more  rare  '  subglenoid'  dis- 
location have  been  erroneously  applied." 

In  a  case  of  alleged  malpractice  tried  in  Marion,  Grant  Co., 
Indiana,  in  April,  1869,  between  Larkin  versus  Jones,  I  was 
called  to  give  testimony  in  relation  to  the  injury  sustained  by 
the  plaintiff.  Mr.  Larkin  had  fallen  from  a  load  of  grain  six 
months  previously,  receiving  an  injury  of  the  shoulder.  Dr. 
Jones  was  summoned  to  treat  the  injury  two  days  after  the 
accident,  and,  as  he  claims,  was  not  permitted  to  make  a  sat- 
isfactory examination  of  the  shoulder,  the  patient  being 
peevish,  and  the  parts  involved  in  the  injury  greatly  swollen 
and  extremely  sensitive.  The  doctor  suspected  the  existence 
of  a  serious  lesion,  such  as  a  fracture  or  dislocation,  but  left 
some  liniment  to  allay  the  inflammation,  and  directions  to  be 
called  again  as  soon  as  the  swelling  and  tenderness  sufficiently 


Dislocation  of  the  head  of 
the  humerus  inwards  (sub- 
coracoid.) 


318  DISLOCATIONS. 

subsided,  to  admit  of  a  satisfactory  examination.  Mr.  Lai-kin 
did  not  send  for  Dr.  Jones  again,  nor  any  other  physician,  but 
let  the  arm  go  as  it  was  for  tour  weeks.  He  then  exhibited 
his  shoulder  to  Dr.  Horn,  who  discovered  the  existence  of  a 
luxation,  and  sent  the  patient  to  Dr.  Win.  Lomax  for  treat- 
ment. It  was  decided  not  to  attempt  reduction  ;  and  Mr. 
Larkin  entered  suit  against  Dr.  Jones  on  the  ground  of  neg- 
lect to  discover  a  dislocation,  and  claimed  ten  thousand  dollars 
as  damages.  At  the  trial  Dr.  Lomax  and  seven  other  prac- 
tising physicians  and  surgeons  of  Marion,  Jonesboro,  and 
vicinity,  testified  that  the  injury  sustained  by  the  plaintiff  \\  as 
a  downward  dislocation  (subglenoid)  of  the  humerus  ;  and 
that  this  was  the  common  form  of  shoulder  dislocation.  In 
my  testimony  and  cross-examination,  1  declared  that  the  head 
of  the  displaced  humerus  in  Mr.  Larkin's  injured  shoulder, 
was  resting  beneath  the  coracoid  process:  and  that  this  was 
the  most  common  form  of  shoulder  dislocations.  The  testi- 
mony was  received  with  marked  discredit  by  the  medical 
friends  of  the  plaintiff;  yet  the  defendant  was  acquitted. 

The  head  of  the  humerus  in  Larkin's  case,  could  be  dis- 
tinctly felt  beneath  the  coracoid  process;  and  measurements 
from  the  acromion  to  the  olecranon  while  the  arm  was  flexed, 
showed  that  the  arm  was  lengthened  to  the  extent  of  half  or 
three-quarters  of  an  inch.  If  the  dislocation  had  been  down- 
wards (subglenoid),  it  would  have  been  lengthened  an  inch 
and  a  half,  or  more  than  the  width  of  the  glenoid  socket. 
Subcoracoid  dislocation  may  be  produced  either  by  a  direct 
force  applied  to  the  head  of  the  humerus,  displacing  it  inwards 
and  forwards,  as  a  blow  or  fall  upon  the  shoulder ;  or,  more 
frequently,  by  forcible  elevation  of  the  lower  end  of  the  bone, 
such  as  may  be  caused  by  a  fall  upon  the  elbow  or  hand,  when 
extended  from  the  body.  In  those  cases  coming  under  my 
observation,  the  cause  of  the  displacement  has  most  frequently 
been  a  fall  upon  the  elbow  or  hand,  though  in  Mr.  Flower's 
cases  direct  violence,  as  falls  or  blows  upon  the  shoulder,  pro- 
duced dislocation  in  the  most  instances.  It  occasionally  hap- 
pens that  the  cause  can  not  be  definitely  ascertained,  the 
patient  bearing  marks  of  violence  in  several  places,  and  not. 
being  able  to  decide  what  force  produced  the  displacement. 
As  a  general  rule,  dislocations  at  any  articulation,  are  rarely 
produced  by  a  direct  blow  on  the  joint.  Mr.  Bryant,  in 


OF  THE    IIUMERUS.  310 

Cooper's  Surgical  Dictionary,  states  that,  "in  thirty-one  out 
of  thirty-four  cases,  the  cause  of  the  injury  was  a  direct  fall 
upon  the  shoulder,  either  forwards,  backwards,  or  outwards. 
In  two  instances  only  of  dislocation  downwards,  and  forwards, 
was  the  bone  displaced  by  a  fall  on  the  extended  arm."  Mai- 
gaigne  says:  "the  subcoracoid  luxation,  which  is  the  most 
common  dislocation,  is  the  effect  of  a  direct  blow  on  the 
shoulder,  the  arm  not  being  raised."  Warren  in  his  Surgical 
Observations,  expresses  the  opinion  that  when  direct  force,  the 
arm  being  by  the  side,  knocks  the  head  of  the  humerus  out 
of  its  socket,  the  rim  of  the  gleuoid  cavity  must  at  the  same 
time  be  broken. 

SYMPTOMS. — Certain  symptoms,  such  as  pain,  want  of  mo- 
tion, and  swelling  in  the  region  of  the  injury,  accompany  all 
dislocations,  but  the  subcoracoid  variety  of  shoulder  disloca- 
tions has  a  few  characteristics  peculiar  to  that  form  of  luxa- 
tion:  the  elbow  projects  from  the  side,  and  can  not  be  made 
to  approach  the  chest  without  causing  pain ;  the  movements 
of  the  forearm  and  hand  are  not  much  impaired,  though  the 
sensation  of  numbness  which  comes  from  pressure  of  the  head 
of  the  humerus  on  the  brachial  plexus  of  nerves,  is  somewhat 
disagreeable.  On  comparing  the  two  shoulders  a  striking 
change  is  observable  on  the  injured  side,  especially  if  the 
patient  be  lean  and  the  injury  recent.  The  natural  roundness 
is  lost,  the  acromion  appears  remarkably  prominent,  and  be- 
neath it  there  is  a  depression  into  which  the  fingers  can  be 
pressed,  proving  that  the  head  of  the  humerus  has  left  its 
socket;  and  in  some  spare  subjects,  even  the  form  of  the 
glenoid  fossa  can  be  distinguished  through  the  fibres  of  the 
deltoid.  The  axis  of  the  humerus  is  evidently  altered  ;  in- 
stead of  being  directed  to  the  glenoid  cavity,  it  points  to  a 
spot  internal,  anterior  to,  and  below  it.  If  the  head  of  the 
humerus  rests  on  the  point  of  the  coracoid  process,  the  arm, 
measuring  from  the  acromion  to  the  external  condyle,  and 
comparing  it  with  the  opposite  side,  is  lengthened;  if  it 
presses  in  behind  the  coracoid  process,  or  gets  forced  within 
•tKat  osseous  projection,  so  as  to  become  subdavicular,  the  arm 
is  shortened.  According  to  Mr.  Flower,  of  forty-four  cases 
of  subcoracoid  dislocation,  the  arm  was  elongated  in  nineteen, 
unaltered  in  eight,  and  shortened  in  seventeen  ;  the  greatest 


820  DISLOCATIONS. 

elongation  being  one  inch,  the  greatest  amount  of  shortening 
seven-eighths  of  an  inch.  Measurement  of  the  vertical  cir- 
cumference of  the  shoulder,  by  carrying  a  tape  over  the  aero- 
mion  and  under  the  axilla,  always  gives  an  increase  of  one  to 
two  inches  over  the  uninjured  side ;  an  important  diagnostic 
sign,  common  to  all  forms  of  dislocation  of  the  humerus,  as 
pointed  out  by  Mr.  Callaway,  in  his  "Dissertation  upon  Dis- 
locations and  Fractures  of  the  Clavicle  and  Shoulder-Joint/' 
The  head  of  the  humerus  can  be  distinctly  felt  beneath  the 
pectoral  muscles;  the  tumor  produced  by  its  globular  form 
can  be  seen;  and  any  movements  imparte.d  to  it  by  rotating 
the  arm  can  be  both  seen  and  felt.  The  head  of  the  humerus 
lies  on  the  anterior  surface  of  the  neck  of  the  scapula,  imme- 
diately below  the  coracoid  process.  The  subscapular  muscle 
is  raised  from  the  neck  of  the  scapula,  and  stretched  over  the 
front  of,  or  above  the  head  of,  the  humerus.  The  muscles 
from  the  back  of  the  scapula  (teres  minor,  and  infra-  and 
supra-spinatus)  are  drawn  tightly  across  the  glenoid  fossa,  or 
one  or  more  of  them  may  be  ruptured,  or  detached  from  the 
bone.  In  some  cases,  the  greater  tuberosity  is  broken  oft', 
and  the  muscles  inserted  into  the  fragment  then  drag  it  into 
the  gleuoid  fossa.  The  tendon  of  the  long  bead  of  the  biceps, 
contrary  to  the  views  of  Hamilton,  is  rarely  broken  asunder, 
or  completely  detached  from  its  insertion.  The  great  vessels 
and  nerves  are  displaced  inwards,  the  circumflex  nerve  being 
either  stretched  or  compressed  to  an  extent  which  frequently 
causes  paralysis  of  the  deltoid  muscle.  I  have  seen  patients, 
years  after  a  successfully  reduced  dislocation  of  the  shoulder, 
who  could  not  raise  the  arm  beyond  an  angle  of  45°  or  50°, 
though  all  the  other  motions  were  perfectly  restored. 

The  capsular  ligament  in  complete  dislocation,  is  torn  suffi- 
ciently to  allow  the  head  of  the  humerus  to  escape  through 
the  aperture ;  and  in  those  cases  that  will  not  stay  in  place 
after  reduction  is  effected,  there  is  a  strong  presumption  that 
the  edge  of  the  glenoid  rim  is  fractured. 

When  left  unreduced  a  new  shallow  socket  is  formed  upon 
the  anterior  surface  of  the  neck  of  the  scapula,  partly  by  the 
absorption  of  old  bone,  and  partly  by  the  deposit  of  new, 
around  its  edge.  The  exact  position  of  this  socket  varies  ac- 
cording to  the  extent  of  the  displacement ;  in  some  instances 
the  new  cavity  is  formed  more  or  less  at  the  expense  of  the 


OF    THE    IIUMERUS. 


321 


FIG.  109. 


New  socket  formed^under  the  coracoid 


anterior  portion  of  the  glenoid  fossa,  which  is  gradually  re- 
moved by  absorption  under  pressure,  so  that  the  original- 
socket  is  greatly  encroached  upon.  A  corresponding  change 

takes  place  in  the  he:'.d  of  the 
humerus  ;  the  part  bearing  upon 
the  edge  of  the  glenoid  fossa,  has 
a  hollow  excavated  in  it,  the  sur- 
faces of  the  two  bones  in  apposi- 
tion accommodating  themselves 
to  each  other,  and  thus  a  rude 
kind  of  joint,  which  allows  of  a 
certain  amount  of  motion,  is 
formed.  The  under  surface  of 
the  coracoid  process,  especially 
near  its  tip,  becomes  smooth  and 
eburnated,  showing  upon  dissec- 
tion that  it  has  contributed  to  the 
formation  of  the  new  articulation. 
In  those  cases  where  the  head 

of   the  humei'llS  is   tlirOWll    within 

the  coracoid  process,  constituting 
the  subclavicular  variety,  or  the  "  intra-coracoid  "  of  Mal- 
gaigne,  the  head  of  the  os  humeri  being  wholly  on  the  sternal 
side  of  the  coracoid  process,  sometimes  coming  forwards  so  as 
to  appear  just  beneath  the  skin,  and  at  others  deeply  buried 
in  the  subscapular  fossa,  the  new  socket  is  not  formed  on  tne 
rim  or  border  of  the  glenoid  fossa,  and  the  globular  extremity 
of  the  humerus  maintains  its  accustomed  shape.  If  the  head 
of  the  humerus  touch  the  inner  surface  of  the  blade  of  the 
scapula,  a  shallow  depression  is  formed  in  that  bone,  and  the 
head  of  the  humerus  is  slightly  flattened  at  a  spot  where  the 
bones  meet,  and  there  becomes  divested  of  its  cartilage,  though 
from  friction  the  parts  in  articular  contact  become  polished 
and  hardened.  If  the  greater  tuberosity  reach  the  anterior 
edge  of  the  glenoid  fossa,  or  any  part  of  the  coracoid  process, 
the  points  of  contact  will  soon  show  the  peculiarities  of  a  new 
articulation.  In  extremely  rare  cases  the  clavicle  has  exhibited 
a  slight  depression  where  the  head  of  the  humerus  has  reached 
it.  How  long  it  takes  to  form  a  new  socket  when  the  head 
of  the  humerus  is  forced  to  take  lodgment  outside  its  normal 
position,  is  not  known,  for  the  history  of  old  dislocations  is 
21 


322  DISLOCATIONS.  , 

seldom  obtained.  Probably  it  requires  a  year  or  more  for  the 
most  of  those  changes  to  occur  which  are  observed  in  ancient 
dislocations.  In  a  specimen  in  St.  Bartholomew's  Hospital 
Museum,  in  which  the  luxation  is  said  to  have  occurred  throe 
months  before  death,  absorption  of  the  anterior  edge  of  the 
glenoid  fossa  has  already  commenced,  and  some  l>one  is  de- 
posited in  the  margin  of  the  ne\v  socket. 

It  is  a  singular  circumstance  that  so  many  surgical  writers 
should  have  regarded  subcoracoid  dislocations  as  "  partial  " 
in  their  nature,  unless  it  came  from  the  fact  that  Sir  Astley 
Cooper,  in  his  treatise  on  Fractures  and  Dislocations,  which 
has  been  "authority"  so  long,  described  an  incomplete  luxa- 
tion of  the  head  of  the  humerus,  of  the  subcoracoid  variety. 
Hamilton, after  reviewing  and  criticizing  the  opinions  of  tho<e 
who  claim  to  have  had  partial  dislocations  to  treat,  sa\s  :  ••  1 
shall  content  myself  with  declaring  that  the  existence  of  this 
or  of  any  other  form  of  partial  luxation  of  the  shoulder-joint, 
as  a  traumatic  accident,  has  not  up  to  this  moment  been  fairly 
established;  and  that  the  anatomical  structure  of  the  joint 
renders  its  occurrence  exceedingly  improbable,  if  not  abso- 
lutely impossible."  It  may  be  remarked,  incidentally  in  this 
place,  that  in  many  of  those  cases  which  have  been  regarded 
as  partial  dislocations  of  the  shoulder,  the  lesion  consisted  of 
a  rupture  or  displacement  of  the  long  head  of  the  biceps  ten- 
don, an  accident  which  is  characterized  by  a  sufficient  dis- 
placement of  the  head  of  the  bone  upwards  and  forwards  be- 
tween the  coracoid  and  acromion  processes,  to  give  the  defor- 
mity the  appearance  of  a  partial  luxation.  The  long  tendon 
of  the  biceps  having  its  origin  from  the  upper  part  of  the  rim 
of  the  socket,  and  passing  over  the  head  of  the  humerus  and 
down  through  the  bicipital  groove  of  that  bone,  serves  to  bind 
the  articular  surfaces  of  the  two  bones  in  close  apposition, 
consequently  a  rupture  of  this  tendon  would  be  followed  by 
more  or  less  displacement  which  might  be  regarded  as  incom- 
plete luxation. 

TREATMENT. — All  scapulo-humeral  dislocations  of  recent  oc- 
currence, can  be  successfully  reduced  by  manipulation  if  the 
patient  be  thoroughly  under  the  influence  of  chloroform  at 
the  time  the  effort  to  replace  the  humerus  is  made.  In  very 
many  cases  no  anaesthetic  is  needed,  but  in  muscular  subjects, 


OF  THE  HUMERUS.  323 

especially  if  the  injury  be  of  two  or  three  days'  standing,  it  is 
useless  to  attempt  a  reduction  before  an  advanced  stage  of 
anaesthesia,  is  reached.  The  use  of  nauseants,  fomentations, 
and  other  relaxing  agencies,  has  been  entirely  superseded  by 
anaesthesia.  The  pulleys,  Jarvis'  Adjuster,  and  other  contriv- 
ances for  multiplying  force,  have  also  lost  their  importance. 

In  a  subcoracoid  dislocation,  as  well  as  in  other  luxations  of 
the  shoulder,  the  projecting  edge  or  rim  of  the  glenoid  socket 
is  an  obstacle  to  reduction;  the  stretched  muscles  and  tense 
liganientous  structures  also  oppose  a  return  of  the  displaced 
bone,  unless  the  arm  be  carried  into  a  position  which  relaxes 
those  tissues.  To  attempt  reduction  by  extension  alone  is  sure 
to  increase  the  strain  on  the  already  overstretched  muscles 
and  ligaments. 

To  proceed  systematically,  whether  chloroform  is  used  or 
not,  let  the  patient  lie  upon  a  sofa,  low  bed,  or  the  floor,  and 
then  the  arm  seized  near  the  elbow  is  to  be  carried  off  from 
the  body  and  elevated  as  much  as  possible;  the  fingers  of  the 
surgeon's  other  hand  rest  upon  the  shoulder  to  steady  the 
scapula,  and  his  thumb. is  pressed  into  the  axilla,  against  the 
head  of  the  humerus,  to  act  in  part  as  a  fulcrum  over  which 
the  patient's  arm  as  a  lever  is  made,  by  a  quick  downward 
movement,  to  pry  the  head  of  the  bone  from  behind  the  pro- 
jecting border  of  the  glenoid  socket,  bringing  the  head  of 
the  humerus  to  a  point  where  the  force  of  the  thumb  and  of 
the  tense  muscles  will  inevitably  complete  the  reduction.  The 
hand  which  has  hold  of  the  patient's  arm  near  the  elbow, 
should  swing  it  slightly  backwards  and  forwards  while  the 
arm  is  forcibly  elevated,  in  order  to  disengage  the  head  of  the 
bone  from  its  place  of  lodgment;  and  then,  in  bringing  the 
dbow  downwards  to  the  side  of  the  thorax,  or  across  the  front 
of  the  chest,  the  motion  is  to  be  imparted  suddenly  in  order 
to  be  as  effective  as  possible.  The  patient,  if  not  under  the 
influence  of  chloroform,  always  holds  the  muscles  in  a  state 
of  rigid  resistance  while  the  surgeon  is  manipulating  the  arm, 
therefore  the  quick^motion  is  expected  to  put  the  patient  off 
his  guard.  It  is  to  be  borne  in  mind  that  the  forearm  should 
be  flexed  on  the  arm  while  manipulation  is  going  on,  that  the 
biceps  may  be  relaxed. 

If  the  first  attempt  at  reduction  fail,  it  will  be  because  the 
scapula  slips  from  the  surgeon's  fingers,  and  destroys  the 


824  DISLOCATION. 

leverage  which  is  designed  to  lift  the  head  of  the  humerus 
from  behind  the  projecting  edge  of  the  glenoid  fossa  ;  there- 
fore another  effort  must  be  made,  and  the  attempts  repeated 
until  success  crowns  the  undertaking.  Those  who  are  not 
strong  in  the  hands  may  use  the  heel  (the  boot  being  removed) 
as  a  fulcrum  in  the  axilla  or  against  the  head  of  the  humerus  ; 
this  leaves  both  hands  free  to  execute  the  reducing  manoeuvres 
upon  the  arm.  Some  surgeons  prefer  to  employ  the  knee  in 
the  armpit  instead  of  the  heel ;  and  to  have  the  patient  lie  011 
the  floor  while  the  manipulation  is  performed.  The  return  of 
the  bone  to  the  socket  is  generally  accompanied  with  an  audi- 
ble snap ;  and  the  natural  mobility  of  the  arm  is  restored  at 
the  same  instant.  In  most  instances  the  natural  contour  of 
the  shoulder  returns  as  soon  as  reduction  is  effected,  but  in 
rare  cases  the  head  of  the  humerus  rests  awkwardly  in  the 
socket,  which,  in  addition  to  the  swelling,  gives  the  region  a 
deformed  appearance. 

Reduction  has  been  accomplished  by  extension  and  coun- 
ter-extension, applied  as  follows:  the  patient  lying  upon  hi.s 
back,  the  surgeon  seated  by  the  affected  side,  places  his  heel 
well  up  into  the  axilla,  so  as  to  press  upon  the  lower  border 
of  the  scapula,  and  then  with  both  hands  hold  of  the  wrist 
exerts  all  the  traction  he  can  command,  all  the  while  rotating 
the  arm  and  endeavoring  to  engineer  the  boife  back  into 
place. 

Surgeons  owning  Jarvis'  Adjuster,  and  having  employed  it 
successfully  in  several  instances,  still  have  faith  in  its  qualities, 
and  persist  in  claiming  that  there  are  cases  that  can  not  be  re- 
duced without  it  as  a  means  of  exerting  powerful  extension 
and  counter-extension. 

I  have  never  met  with  a  recent  dislocation  of  the  shoulder 
that,  in  my  present  belief,  could  not  have  been  reduced  by 
manipulation,  the  patient  being  thoroughly  under  the  influence 
of  chloroform.  In  October,  '68, 1  was  called  to  Hamilton,  O., 
to  assist  in  the  reduction  of  a  subcoracoid  dislocation  of  the 
humerus  which  fell  into  the  hands  of  Drt  Markt.  Several 
futile  attempts  had  been  made  to  effect  a  reduction  ;  and  their 
failure,  in  my  opinion,  depended  upon  imperfect  anaesthesia. 
The  patient  was  a  young  German,  of  remarkable  muscular  de- 
velopment; and  possessed  a  nervous  system  that  would  bear 
an  unusual  amount  of  chloroform  without  being  overcome. 


OF  THE  HUMERUS.  325 

I  used  eight  or  ten  ounces  of  the  best  chloroform  on  a  hand- 
kerchief held  quite  close  to  the  hose  before  stertorous  breath- 
ing was  produced.  As  soon  as  that  stage  of  profound  anres- 
tliesia  was  reached,  the  muscular  system  became  relaxed,  and 
reduction  took  place  by  the  force  of  the  hands  alone. 

In  some  cases  which  for  some  time  resist  the  usual  efforts  at 
reduction,  it  is  found  that  success  attends  modifications  of  the 
ordinary  procedure  ;  for  instance,  the  arm  is  to  be  carried  for- 
cibly backwards  as  well  as  upwards,  or  it  has  to  be  extended 
by  the  force  of  two  or  tbree  assistants,  to  effect  some  change 
in  the  position  of  the  head  of  the  humerus,  or  relieve  it  from 
the  restraining  influence  of  the  untorn  portion  of  the  capsular 
ligament,  or  to  perform  some  other  feat  more  empirical  than 
scientific,  which  shall  so  modify  the  relations  of  the  parts  in- 
volved in  the  injury,  as  may  result  in  an  easy  replacement  of 
the  luxated  bone.  I  have  seen  a  person  inexperienced  in  the 
management  of  dislocations  reduce  a  displaced  bone  that  had 
baffled  a  skillful  surgeon  for  hours.  However,  there  are  not 
enough  of  such  chance  cases  to  justify  an  entire  dependance 
upon  the  results  of  blundering.  t 

After  reduction  has  been  accomplished,  the  joint  should  be 
kept  at  rest  for  two  or  three  weeks,  the  arm  being  placed  in  a 
sling,  with  the  elbow  bound  to  the  side.  It  may  be  well  to 
guard  against  elevating  the  elbow  or  throwing  it  outwards  and 
upwards  for  several  months.  A  recurring  dislocation  is  a  great 
perplexity,  therefore  it  is  best  to  follow  precautions  likely  to 
prevent  such  accidents. 

The  subclavicular  variety  of  dislocation  is  generally  very 
difficult  to  manage.  The  coracoid  process  is  an  obstacle  in 
the  path  leading  to  a  return  of  the  head  of  the  humerus. 
The  arm  must  be  drawn  downwards  so  the  head  of  the 
humerus  may  pass  clear  of  that  process ;  and  then  manipulated 
as  if  the  displacement  were  of  the  common  variety.  The 
heel  in  the  space  between  the  arm  and  the  chest,  with  both 
hands  exerting  extension  and  rotation,  will  generally  effect  a 
dislodgmeut  of  the  luxated  bone,  and  successful  reduction. 


326 


DISLOCATIONS. 


FIG.  110. 


SUBGLENOID    DISLOCATION    OF    THE     HUMERUS 

What  is  generally  called  the  "  downward,"  "  downward  and 
inward,"  and  "axillary"  luxation  of  the  shoulder,  is  a  dis- 
placement of  the  head  of  the  humerus  so  that  it  occupies  a 
position  below  the  socket,  the  capsular  ligament  being  torn  at 
its  lower  part.  This  has  commonly  been  regarded  by  surgical 
writers  as  the  most  frequent  luxation  of  the  humerus,  but  as 
I  have  already  stated  in  another  place,  the  lesion  is  far  less 
frequent  than  the  subcoracoid  variety  of  shoulder  dislocations. 
The  head  of  the  humerus  being  thrown  below  the  glenoid 
fossa,  finds  lodgment  upon  the  inner  border  of  the  inferior 
costa  of  the  scapula,  somewhat  as  represented  in  Hie  accom- 
panying diagram  (Figure  110).  Why  the  globular  head  of 

the  os  humeri  should  ever  become 
poised  on  the  thin  border  of  the 
blade-bone,  is  almost  a  mystery,  but 
there  it  has  been  found  in  a  few  in- 
stances. Probably  the  untorn  edge 
of  the  capsular  ligament  prevents 
the  head  of  the  humerus  from  rising 
up  to  a  point  beneath  the  coracoid 
process.  An  examination  of  the 
scapula  shows  that  the  inferior  costa 
of  the  bone  terminates  in  two  crests, 
leaving  a  wide  groove  between  them 
at  a  point  c6rresponding  with  the 
cervix  scapulae.  In  this  scaphoid 
fossa  the  head  of  the  humerus  finds 
lodgment ;  and  the  inner  of  the  two 
crests  or  borders  of  the  groove  pre- 
vents the  humerus  from  sliding  up- 
wards. Mr.  Flower  says,  that  "  In  the  only  two  specimens 
of  unreduced  dislocations  of  this  kind  that  1  have  been  ahle 
to  find  in  the  anatomical  museums  of  London,  a  new  osseous 
socket  has  formed  for  the  head  of  the  humerus  on  the  nppei 
part  of  the  anterior  border  of  the  inferior  costa  of  the  scapula, 
encroaching  considerably  upon  the  lower  and  anterior  part  of 
the  glenoid  fossa.  One  of  these  has  been  figured  by  Sir  A. 
Cooper,  and  its  subsequent  reproduction  by  other  authors 


Subglenoid  dislocation  of  the 
humerus. 


OF  THE  HUMERUS.  327 

contributed  much  to  confirm  the  error  of  regarding  this  as 
the  usual  form  of  dislocation  at  the  shoulder.  From  exami- 
nations of  specimens  in  museums,  and  from  numerous  recent 
cases,  I  should  conclude  that,  not  more  than  one  in  ten  of  all 
dislocations  of  the  humerus  can  properly  be  called  subglenoid." 
There  is  a  specimen  in  King's  College  Museum,  (No.  1342), 
which  is  intermediate  between  subcoracoid  and  subglenoid. 

The  servile  copying  of  diagrams  from  Cooper's  work  on 
Fractures  and  Dislocations,  and  the  wording  of  the  text  to 
conform  to  the  illustrations,  has  done  much  towards  perpetu- 
ating errors  even  in  recent  works  on  Surgery.  Old  figures 
representing  reductions  of  the  humerus  and  femur  by  means 
of  pulleys,  and  other  appliances,  showing  how  to  employ  ex- 
tension and  counter-extension  as  methods  of  reduction,  have 
contributed  more  than  any  other  influence  to  perpetuate  bar- 
barous practices  in  the  application  of  force.  Even  if  better 
methods  of  reducing  dislocated  bones  are  described  in  the 
text,  many  indolent  practitioners  will  neglect  the  printed 
directions,  and  be  governed  only  by  the  pictures  which  make 
deeper  impressions  than  prosy  descriptions. 

The  symptoms  of  subglenoid  dislocation  of  the  shoulder  are 
not  strikingly  different  from  those  manifested  in  the  subcora- 
coid variety  of  luxation.  The  depression  beneath  the  acro- 
mion  process  is  greater ;  the  arm  is  lengthened  to  the  extent 
of  the  diameter  of  the  glenoid  fossa,  unless,  in  being  worked 
at,  the  head  of  the  bone  leaves  the  bifid  ridge  on  which  it 
usually  rests  and  becomes  embedded  deeply  in  the  subscapular 
fossa  ;  and  there  is  an  inch  or  more  of  spacfe  between  the  head 
of  the  humerus  and  the  coracoid  process.  Measurements  are 
uncertain  unless  they  be  conducted  with  great  care,  both  arms 
being  made  to  assume  the  same  positions  while  measured,  al- 
lowance being  also  made  for  the  rotated  attitude  of  the  injured 
arm.  In  this  as  in  the  subcoracoid  variety  of  dislocation  the 
patient  is  unable  to  make  the  hand  of  the  injured  side  touch 
the  sound  shoulder ;  neither  can  the  surgeon  execute  the 
manoeuvre  unless  the  patient  be  under  the  influence  of  chloro- 
form ;  and  then  there  would  be  danger  of  lacerating  the  tense 
tissues  in  the  endeavor.  The  rigid  condition  of  the  arm,  its 
ugly  projection  from  the  side,  the  painful  numbness  of  the 
whole  limb,  and  disposition  of  the  patient  to  support  the  arm 
with  the  well  hand,  constitute  signs  that  point  pretty  clearly 


828  DISLOCATION.-. 

to  sonic  kind  of  a  seapulo-liumeral  dislocation.  The  causes 
of  subglenoid  dislocation  of  the  shoulder  are  direct  violence 
upon  the  top  of  the  humerus,  falls  upon  the  hand  or  elbow 
while  the  body  is  descending,  and  the  forcible  elevation  of  the 
elbow,  making  the  acromion  a  fulcrum  over  which,  the  lever- 
age of  the  arm  is  sufficient  to  tear  the  capsular  ligament  on 
its  under  side  and  contribute  to  the  displacement.  Muscular 
action  while  the  arm  and  elbow  are  quickly  thrown  upward, 
lias  been  known  to  produce  the  "  downward  "  luxation. 

TREATMENT. — The  management  of  a  subglenoid  dislocation 
does  not  differ  essentially  from  that  already  laid  down  for  the 
reduction  of  a  subcoracoid  dislocation.  The  arm  is  to  be 
seized  just,  above  the  elbow  and  carried  forcibly  upward  and 
outward,  and  the  scapula  is  to  be  fixed  by  the  exertion  of  the 
fingers,  while  the  thumb  performs  the  part  of  a  fulcrum  and 
helps  push  the  head  of  the  humerus  into  place  at  the  instant 
the  quick  downward  and  inward  movement  of  the  arm  is  ex- 
ecuted. One  attempt  failing,  several  repeated  efforts  should 
be  made,  each  being  somewhat  different  from  the  preceding 
in  order  to  give  variety  to  the  manoeuvres.  The  heel  or  knee 
being  placed  in  the  axilla,  both  hands  can  be  used  in  extend- 
ing, rotating,  and  sweeping  the  arm  from  a  position  of  extreme 
elevation  to  one  of  extreme  depression  alongside  or  across  the 
chest.  One  hand  holds  the  forearm  flexed  and  the  other 
guides  the  elbow.  Chloroform  should  be  freely  employed  in 
all  cases  that  resist  the  first  efforts  or  are  extremely  painful. 
If  the  surgeon  sees'the  patient  soon  after  the  accident,  he  may 
be  able  to  effect  reduction  without  resort  to  anaesthetics.  F 
have  reduced  a  dislocated  shoulder  without  even  waiting  to 
take  off  the  patient's  coat.  1  have  seen  the  armpit  severely 
bruised  by  the  surgeon's  boot  in  attempts  at  reduction  ;  and 
here  express  my  disapprobation  of  such  rough  usage.  I  have 
also  seen  the  arm  above  the  wrist  and  elbow  terribly  excoriated 
by  the  action  of  towels  and  straps  employed  in  making  exten- 
sion. Proper  care  manifested  during  manipulation  saves  the 
patient  from  these  painful  and  unsightly  marks.  A  bold  and 
efficient  surgeon  generally  acquires  the  reputation  of  being 
rough,  and  he  deserves  this  disci-edit  if  he  heedlessly  and 
heartlessly  inflicts  unnecessary  injuries  upon  his  patients. 
Skillful  and  gentle  manipulations  accomplish  more  in  reducing 


OF    THE    IIUMERUS. 


dislocated  bones  than  brute  force  put  forth  without  a  rational 
method  in  view.  The  retentive  dressing  to  be  employed  after 
reduction  is  effected,  may  be  the  same  in  all  kinds  of  shoulder 
dislocations.  The  arm  is  to  be  suspended  in  a  sling,  and  tied 
to  the  side  for  two  or  three  weeks  ;  and  rare  exercised  about 
elevating  the  arm  for  several  months. 


Fm.  111. 


SUBSPINOUS    DISLOCATION    OF    THE    SHOULDER. 

What  has  been  generally  called  a  "  backward  "  luxation  of 
the  humerus,  the  head  of  the  bone  being  forced  from  its 
usual  position  to  one  beneath  the  spine  of  the  scapula,  outside 

of  the  glen oid  socket,  is  an  injury 
of  uncommon  occurrence.  Out  of 
159  cases  of  scapnlo-humeral  luxa- 
tion recorded  in  the  Middlesex 
Hospital,  three  were  of  this  variety. 
Its  characters  are  so  well  marked, 
that  it  is  not  liable  to  be  confounded 
with  any  of  the  others.  There  are 
said  to  be  four  good  specimens,  il- 
lustrating its  effects,  when  left  un- 
reduced, in  the  different  anatomical 
museums  of  London.  The  head  of 
the  bone,  when  dislocated  back- 
subsPinous,H8ioeation  or  the  humerus.  wards,  would  until  rally  rest  on  the 

neck  of  the  scapula  near  the  pos- 
terior edge  of  the  glenoid  fossa,  but  in  case  the  displacing 
force  continued  after  the  luxation  was  accomplished,  the  head 
of  the  humerus  might  be  driven  back  two  or  three  inches 
upon  the  dorsum  of  the  scapula.  In  cases  of  great  displace- 
ment the  lesser  tuberosity  of  the  humerus  is  found  to  be  sep- 
arated (broken),  or  the  tendon  of  the  subscapularis  is  detached 
from  its  humeral  connection. 

In  an  unreduced  dislocation  of  several  years'  standing, 
which  I  once  had  the  opportunity  to  dissect,  I  found  the  part 
of  the  head  of  the  humerus  which  rested  against  the  posterior 
edge  of  the  socket  and  the  neck  of  the  scapula,  somewhat 
flattened  and  eburnated ;  and  a  new  socket  had  formed, 
slightly  excavating  the  blade,  and  considerably  the  base  of  the 


330  DISLOCATIONS. 

acromion.  There  was  very  little  osseous  material  thrown 
around  the  new  socket.  Pressure  of  the  head  of  the  humerus 
upon  the  posterior  edge  of  the  glenoid  rim  had  caused  some 
encroachment  upon  that  segment  or  ledge  of  bone,  but  the 
articular  face  of  the  gleuoid  cavity  had  not  been  altered. 
The  tendon  of  the  subscapular  muscle  had  been  torn  from  its 
humeral  attachment,  and  the  old  capsular  ligament  was  thinned 
and  in  places  lost  by  being  blended  with  the  other  soft  tissues 
of  the  region. 

The  head  of  the  bone  formed  a  marked  protuberance  be- 
neath and  outside  of  the  acromion,  giving  the  shoulder  the 
appearance  of  being  widened  on  that  side ;  the  depression  be- 
tween the  acromion  and  the  coracoid  processes,  was  not 
marked,  but  could  be  distinctly  felt  by  pressing  the  fingers 
into  the  old  socket.  The  elbow  was  inclined  to  take  a  posi- 
tion a  little  more  inward  than  natural.  Whatever  may  have 
been  the  rigidity  of  the  arm  directly  after  the  accident,  or  the 
restrictions  upon  a  wide  range  of  motion,  at  the  time  of  the 
patient's  death  the  limb  could  be  moved  freely  in  every 
direction. 

The  causes  of  subspinous  dislocation  would  probably  be 
falls  upon  the  arm  while  the  elbow  is  thrown  forcibly  in  front 
of  the  chest.  At  any  rate,  this  seems  to  be  the  only  way  a 
dislocation  of  the  kind  can  be  produced  in  the  cadaver.  The 
few  surgeons  who  have  had  a  case  to  treat  were  not  generally 
able  to  ascertain  the  position  of  the  arm  when  luxation  oc- 
curred, or  the  positive  and  direct  cause  of  the  accident.  Con- 
vulsive muscular  action  is  said  to  have  produced  the  luxation 
in  one  instance,  and  falls  of  various  kinds  in  the  others.  The 
dislocation  was  not  always  discovered  until  days  or  work- 
after  the  accident,  yet  reduction  was  accomplished  in  nearly 
every  case,  though  the  head  of  the  bone  had  been  displaced 
for  a  number  of  days  before  an  attempt  at  reduction  was 
made. 

TREATMENT. — The  rule  for  reducing  this  form  of  dislocation 
is  to  stand  behind  the  patient  who  is  seated  in  a  chair  or  on  a 
stool ;  the  surgeon  with  one  hand  takes  hold  of  the  back  of 
the  arm  near  tlje  elbow  and  forces  it  across  the  chest,  in  front, 
as  far  as  it  will  go  ;  he  then  puts  the  other  hand  on  the  top  of 
the  shoulder,  the  lingers  resting  on  the  acromion  to  steady  the 


OF  TUB  HUMERUS.  331 

scapula,  and  to  lend  efficiency  to  the  thumb  in  the  work  of 
being  a  fulcrum  and  in  pushing  the  head  of  the  humerus  into 
place  when  the  patient's  arm  is  suddenly  swung  backwards. 
This  manoeuvre,  accomplished  by  both  hands  operating  sep- 
arately, will  replace  the  bone,  especially  if  the  patient  be 
thoroughly  relaxed  by  the  influence  of  anaesthetics. 

Direct  extension  has  proved  effectual  in  reducing  this  dislo- 
cation. In  fact,  any  dislocation  of  the  shoulder  may  be  re- 
duced with  the  pulleys  and  other  appliances  for  exerting  great 
force,  yet  the  mechanical  resistance  offered  by  the  untorn  por- 
tion of  the  capsular  ligament,  is  such  that  the  bone  can  not 
be  replaced  by  extension  without  lacerating  the  tissues  made 
more  tense  by  the  operation.  Extension  drags  the  head  of 
the  bone  away  from  the  opening  in  the  ligament  through 
which  it  escaped,  and  places  the  caput  humeri  in  a  position 
unfavorable  to  an  easy  return  over  the  glenoid  rim. 

Mr.  Flower  gives  the  following  plan  which  he  has  never 
known  to  fail :  "  The  patient  is  seated  on  a  high  chair,  which 
is  placed  about  two  feet  from  the  post  of  an  open  doorway. 
The  surgeon,  leaning  his.  back  against  the  door-post,  places 
one  foot  upon  the  side  of  the  chair,  and,  with  his  knee  pressed 
into  the  axilla  and  both  hands  upon  the  shoulder,  steadies  the 
patient's  body.  A  jack-towel  is  then  fixed  by  a  clove-hitch 
knot  to  the  patient's  arm,  just  above  the  elbow ;  and  by  its 
means  two  or  more  assistants,  placed  on  the  other  side  of  the 
doorway,  make  steady  extension  horizontally  outwards." 
This  plan  is  for  reducing  dislocations  "  downwards"  and  "  for- 
wards," but  is  open  to  the  same  objections  as  other  contriv- 
ances to  produce  extension.  It  is  found  to  be  an  unscientific 
plan  for  reducing  dislocations,  and  though  it  will  yet  be  fol- 
lowed by  a  few  superannuated  practitioners,  the  more  rapid, 
and  less  dangerous  "  physiological  "  process,  now  so  well  un- 
derstood, continues  to  gain  favor,  and  rarely  or  never  fails 
where  success  by  any  method  is  possible. 

Compound  Dislocation  of  the  Shoulder . — It  has  been  a  ques- 
tion whether  a  compound  dislocation  of  the  shoulder  should 
be  reduced,  or  the  head  of  the  humerus  resected.  Although 
I  have  never  had  such  an  injury  to  treat  at  the  shoulder-joint, 
I  am  persuaded  that  I  should  proceed  at  once  with  an  attempt 
at  reduction.  If  the  head  of  the  bone  would  not  return 
through  the  hole  in  the  skin  I  should  enlarge  the  opening. 


332  DISLOCATIONS. 

and  then  make  a  powerful  effort  at  reduction.  If  this  course 
failed  it  would  then  be  in  order  to  exsect  the  head  of  the 
humerus  and  enough  of  the  shaft  to  facilitate  a  return  of  the 
bone  to  its  place. 

Dislocation  of  the  Humerus,  with  Fracture  near  the  Upper  Eml 
of  the  Bone. — The  older  surgical  writers  declared  that  a  dislo- 
cation of  the  shoulder,  complicated  with  fracture  of  the 
humerns  near  its  upper  extremity,  could  not  be  reduced  until 
the  fracture  had  united.  Dr.  J.  M.  Warren,  in  his  Surgical 
Observations,  says,  "  I  have  had  to  treat  several  cases  of  dislo- 
cation of  the  shoulder,  with  fracture  of  the  neck  of  the 
humerus.  In  two  instances  in  which  I  was  called  while  the 
muscles  were  still  relaxed,  and  before  the  patient  had  recovered 
from  the  depressing  influence  of  the  shock,  it  was  found  pos- 
sible to  effect  reduction  by  making  extension  of  the  shaft  of 
the  bone,  at  the  same  time  working  the  separated  head  into 
its  socket  by  firm  pressure  with  the  thumbs.  In  case  reduc- 
tion can  riot  be  thus  effected,  it  is  still  a  question  whether  the 
shaft  of  the  bone  should  be  carried  back  into  the  old  socket. 
so  as  thus  to  make  at  once  the  best  practicable  joint ;  or 
whether  it  should  be  placed  in  apposition  with  the  head,  and 
an  attempt  made  at  reduction  after  such  a  lapse  of  time  as 
may  be  thought  sufficient  for  the  union  of  the  fragment 
take  place.  The  latter  method  was  tried  with  success,  by  Dr. 
John  C.  "Warren,  on  a  }roung  man,  whose  case  he  reported  in 
the  *  Boston  Medical  and  Surgical  Journal'  for  1828.  Im- 
mediate reduction  having  been  attempted  in  vain,  fracture- 
apparatus  was  applied.  After  seven  weeks,  extension  was 
made  with  pulleys,  and  the  dislocation  reduced.  The  case  is 
quoted  by  Malgaigne,  who  considers  the  pnredtnt  worthy  to 
be  followed  in  similar  eases.  I  also  attempted  the  same  treat- 
ment in  a  case  which  occurred  nearly  twenty  years  ago  ;  hut, 
in  the  attempt  to  break  up  the  adhesions  which  had  formed 
during  the  six  or  eight  weeks  that  had  elapsed,  the  callus 
gave  way,  and  the  fracture  was  reproduced.  The  broken  end 
of  the  bone  was  then  placed  in  the  glenoid  cavity,  and  the 
patient  recovered  with  a  very  useful  arm.  In  another  case 
which  came  under  my  notice,  the  arm  had  been  paralyzed  by 
fruitless  attempts  at  reduction.  I  saw  the  patient,  in  consul- 
tation with  other  surgeons,  at  the  end  of  seven  -\\eeks,  when 
it  was  decided  to  leave  the  broken  end  of  the  hone  in  the 


OP    THE    IIUMERUS.  333 

socket.  I  afterwards  learned  that  the  paralysis  gradually 
passed  oft',  and  that  the  patient  recovered  the  use  of  the 
arm." 

If  the  fracture  be  at  some  distance  from  the  head  of  the 
liumerus  the  limb  could  be  temporarily  dressed  firmly  with 
splints,  and  then  employed  as  a  lever  as  if  no  fracture  had 
occurred ;  and  if  the  break  be  near  the  head  of  the  liumerus, 
the  head  itself  might  possibly  be  pushed  into  place  by  the 
power  of  the  thumbs,  especially  if  the  patient  be  profoundly 
under  the  influence  of  chloroform.  The  first  attempt  failing, 
repeated  efforts  may  be  made  every  day  for  a  week  or  more. 

Dr.  Watson,  of  New  York,  reported  u  case  to  the  Academy 
of  Medicine,  in  May,  1855,  in  which  dislocation  of  the  humerus 
existed,  and  a  fracture  near  the  head  of  the  bone.  The  in- 
jury was  produced  by  a  blow  from  a  steam  engine;  and  the 
patient  was  not  treated  until  the  morning  after  the  accident. 
A  sweeping  motion  was  given  to  the  arm  while  the  lingers 
were  pressed  against  the  head  of  the  bone  in  the  axilla,  and 
reduction  was  effected.  The  arm  was  then  treated  for  a  suc- 
cessful cure  of  the  fracture. 

It  remains  a  question  in  the  event  that  attempts  at  reduc- 
tion failed,  whether  it  is  best  to  adjust  the  fracture  and  retain 
the  fragments  in  apposition  until  osseous  union,  has  taken 
place,  trusting  to  a  successful  reduction  of  the  dislocation  at 
the  end  of  six  weeks,  or  after  the  fragments  are  presumed  to 
be  sufficiently  consolidated  to  allow  the  arm  to  be  safely 
handled  in  the  manipulating  process  necessary  to  accomplish 
reduction  ;  or  to  place  the  broken  end  of  the  shaft  in  the 
empty  glenoid  cavity,  trusting  to  the  usefulness  of  a  joint  ob- 
tained under  such  circumstances.  1  am  inclined  to  the  belief 
that  it  is  best,  if  the  reduction  can  not  be  effected  at  trials 
made  during  the  first  ten  days,  to  treat  the  fracture  with  the 
broken  end's  in  apposition,  and  at  the  expiration  of  six  or 
seven  weeks,  or  after  consolidation  of  the  fragments  is  pre- 
sumed to  have  taken  place,  attempt  to  effect  a  reduction  of 
the  dislocation.  It  is  well  known  that  a  dislocated  shoulder, 
if  left  unreduced,  at  length  regains  a  great  part  of  its  useful- 
ness, or  as  much  at  least  as  an  arm  would  have,  which  had  a 
joint  made  of  the  fractured  shaft  placed  directly  in  the  gle- 
noid socket. 


•334  DISLOCATIONS. 

In  rare  instances  the  fragments  would  fail  to  unite,  a  false 
joint  being  established1.  Such  a  termination  would  not  he 
worse  than  a  union  of  the  fragments  with  the  bone  unre- 
duced ;  or  a  joint  produced  from  the  broken  end  of  the  long- 
fragment  of  the  humerus,  the  short  fragment  being  left  to 
itself  in  the  axilla. 

If  a  patient  with  a  dislocated  shoulder  and  fracture  of  the 
humerus  near  its  upper  extremity,  be  put  profoundly  under 
an  anesthetic,  the  short  fragment  can  be  manipulated  with 
considerable  ease,  especially  if  the  patient  be  not  too  muscu- 
lar. I  have  recently  had  such  a  complicated  injury  in  a  lad 
twelve  years  of  age.  The  accident  happened  by  a  fall  from  a 
horse  that  was  frantically  running  away.  Tlie  boy  says  the 
dislocation  occurred  first,  and  the  fracture  immediately  after- 
wards. I  laid  the  patient  upon  a  low  bed,  and  produced  ster- 
torous breathing  with  chloroform  ;  and  then  manipulated  the 
short  upper  fragment  of  humerns  for  nearly  an  hour.  At 
length  I  got  the  position  all  right  for  a  return  of  tlie  head  of 
the  bone  through  the  aperture  in  the  capsular  ligament,  and 
with  my  thumb  pushed  the  luxated  part  into  its  socket.  At 
lirst  the  swelling  and  stiffness  seemed  to  impede  and  balk  my 
efforts,  but  the  longer  I  worked  tlie  easier  it  was  to  render 
the  conditions  favorable  to  reduction.  The  arm  was  carried 
to  position  as  if  no  fracture  existed,  and  the  fractured  sur- 
faces of  the  two  fragments  were  kept  in  apposition  during 
the  movements.  3To  other  rules  can  be  given  in  regard  to  the 
management  of  such  a  case.  As  soon  as  reduction  of  the 
luxation  occurs  the  limb  is  to  be  carefully  dressed  to  secure  a 
good  result  from  the  fracture. 

I  have  examined  a  case  in  which  there  seems  to  have  been 
dislocation  of  the  shoulder  and  separation  of  the  epiphysis — 
head  from  shaft — in  a  little  girl.  The  accident  occurred  more 
than  a  year  previously,  therefore  I  did  not  undertake  to  re- 
duce the  luxation.  The  head  of  the  bone  and  the  shaft  had 
united  at  an  angle  that  was  beneficial  rather  than  otherwise. 
The  deformity  was  not  great,  and  the  functions  of  the  limb 
were  better  than  might  be  expected.  The  mother  reported 
that  the  child  was  regaining  the  use  of  its  arm  very  rapidly. 
It  was  easy  to  diagnose  the  injury,  from  the  fact  that  the  head 
of  the  humerus  was  out.  of  its  soeket,  and  the  angle  alluded 
to  presupposes  fracture. 


CHAPTER    VIII. 


DISLOCATION  OF  THE  RADIUS  AND  ULNA  AT  THE 
ELBOW-JOINT. 


Dislocation  of  the  elbow,  both  bones  of  the  forearm  being 
displaced,  is  not  a  common  Accident,  and  occurs  mostly  in 
childhood  and  youth.  The  injury,  according  to  statistical 
tables,  is  peculiar  to  boys  between  the  ages  of  five  and  fifteen 
years.  Of  thirty-three  cases  observed  by  Hamilton,  nineteen 
were  in  children  under  fourteen  years  of  age. 

Malgaigne  concludes,  from  experiments  upon  the  dead  sub- 
ject, and  from  careful  examination  and  interrogation  of 
patients  who  have  met  with  the  accident,  that  the  most  fre- 
quent cause  of  nearly  every  form  of  luxation  at  the  elbow- 
joint,  is  a  twist  given  to  the  ulna,  which  brings  the  coronoid 
process  successively  inwards,  downwards,  and  backwards,  and 
which  may  be  produced  by  a  fall  upon  either  the  internal 
border  of  the  forearm,  or  the  inner  side  of  the  olecranon. 
Other  authors  state  that  this  injury  is  more  frequently  effected 
by  a  fall  in  which  the  palm  of  the  hand  comes  into  violent 
contact  with  the  ground,  so  that  the  forearm  is  driven  directly 
back  under  the  lower  end  of  the  humerus.  Hamilton  has 
known  one  case  to  occur  from  a  blow  upon  the  back  and 
lower  part  of  the  humerus. 

The  bones  may  be  displaced  backwards,  forwards,  or  to 
either  side ;  there  also  may  be  intermediate  forms,  as  back- 
wards and  outwards,  and  backwards  and  inwards.  Each  form 
may  be  partial  or  complete,  and  one  or  both  bones  may  be 
displaced;  or  the  ulna  may  be  dislocated  backwards  as  regards 
the  lower  end  of  the  humerus,  and  the  radius  forwards. 
Some  of  these  different  forms  of  dislocation  may  be  compli- 
cated with  fracture  of  the  olecranon  or  coronoid  process  of 
the  ulna ;  either  of  the  condyles  of  the  humerus  may  be 
broken;  and  the  injury  may  be  compound. 

(335) 


836 


DISLOCATIONS. 


The  complex  structure  of  the  elbow-joint,  and  the  depth  to 
which  portions  of  the  articulation  are  buried  in  muscles,  to- 
gether with  the  great  swelling  to  which  all  lesions  of  the  parts 
are  especially  liable,  render  any  of  the  injuries  peculiar  to  the 
bones  exceedingly  difficult  to  diagnose.  Fracture  of  the 
humerus  just  above  the  elbow  takes  the  semblance  of  dislo- 
cations of  both  bones  of  the  forearm  backwards ;  fracture  of 
either  condyle  may  be  mistaken  for  a  luxation  of  one  or  both 
bones  of  the  forearm  ;  and  a  complication  of  fractures  and 
dislocations  mav  result  from  a  single  accident. 

v  O 

The  elbow-joint  is  exceeding!}'  liable  to  high  grades  of  in- 
flammation, and  to  anchylosis  after  a  fracture  implicating  the 
articulation,  or  a  dislocation.  Many  of  the  injuries  peculiar 
to  the  elbow  either  pass  unrecognized  or  are  badly  treated. 
therefore  more  deformities  of  this  joint  are  to  be  met  than 
of  any  other  articulation.  It  is  of  the  utmost  importance, 
then,  that  the  anatomy  and  pathology  of  the  elbow  bo  well 
studied. 

Some  forms  of  elbow  dislocation  are  exceedingly  rare  :  lux- 
ation of  both  bones  of  the  forearm  backwards  and  upwards  is 

the  most  common  of  all  of  them. 
"When  this  is  complete,  the  conmoid 
process  (if  not  fractured)  is  forced 
back  into  the  olecranon  l'<>->u  of  the 
humerus.  According  to  Malgaigne, 
this  condition  is  not  so  common  as 
the  incomplete  form,  in  which  the 
process  rests  upon  the  trochlea  of 
the  humerus.  The  radius  almost 
always  maintains  its  relative  posi- 
tion to  the  ulna,  being  held  there  by 
the  orbicular  ligament.  All  the  lig- 
aments of  the  elbow  joint,  except 
the  posterior,  are  generally  torn  in 
a  dislocation  of  the  radius  and  ulna. 
The  symptoms  in  this  dislocation  of 
both  bones  of  the  forearm  back- 
wards, are  marked  and  characteris- 
tic ;  the  limb  is  in  a  semi-flexed 
state,  and  rigid ;  the  elbow  seems  to  be  thicker  antero-poste- 
irorly,  and  the  olecranon  projects  backward  in  a  marked  de- 


Fio.  112. 


Dislocation  of  radius    and   ulna 
backwards. 


OF  THE  RADIUS  AND  ULNA.  337 

gree,  reaching  above  the  condyles  of  the  humerus;  the  triceps 
tendon  stands  out  conspicuously,  though  it  is  not  tense  ;  the 
forearm  generally  exhibits  a  twisted  appearance,  inclining 
strongly  to  pronation.  When  the  hand  is  rotated  the  head  of 
the  radius, behind  the  humerus,  can  be  felt  rolling  in  its  usual 
relation  with  the  ulna.  Anteriorly,  as  if  embedded  in  the 
flesh  of  the  forearm,  the  lower  end  of  the  humerus  can  be 
felt,  with  the  tendon  of  the  biceps  and  the  brachialis  anticus 
muscle  stretched  over  it.  Any  attempt  to  Hex  or  extend  the 
elbow  is  found  to  be  painful  and  quite  impracticable.  In 
front  the  forearm  is  shortened  to  a  noticeable  extent,  while 
the  posterior  aspect  retains  its  usual  length.  The  fingers  are 
moderately  flexed,  and  can  not  be  moved  with  ease;  the}7  are 
also  benumbed  by  pressure  on  the  nerves  above. 

If  great  swelling  has  taken  place  before  the  injured  limb  is 
seen,  and  any  doubt  arises  in  regard  to  the  nature  of  the 
lesion,  it  may  assist  in  the  diagnosis  to  bear  in  mind  that  only 
one  injury  appears  like  a  dislocation  of  both  bones  of  the 
forearm  backwards,  and  that  is  fracture  of  the  humerus  just 
above  the  condyles,  and  the  distinction  between  the  two  inju- 
ries may  be  drawn  as  follows  :  in  dislocation  the  arm  is  rigid, 
and  the  deformity  can  not  be  overcome  without  reduction, 
which  is  accomplished  with  difficulty,  and  when  once  replaced 
the  bones  will  stay  there  ;  while  in  fracture,  there  is  great 
mobility  at  the  seat  of  injury,  the  reduction  is  accomplished 
with  comparative  ease,  and  when  the  reducing  force  is  dis- 
continued the  deformity  will  at  once  be  reproduced.  Besides, 
in  the  event  of  fracture  of  the  humerus,  crepitus  can  readily 
be  elicited. 

A  lateral  displacement  of  the  bones  of  the  forearm  at  the 
elbow  may  be  readily  recognized  by  the  peculiarities  of  the 
deformity.  In  most  instances  the  luxation  is  incomplete,  i.  e., 
both  bones  are  not  thrown  so  far  laterally,  as  to  have  no  con- 
tact with  the  articular  surfaces  of  the  lower  extremity  of  the 
humerus.  In  the  outward  dislocation,  which  is  the  most  com- 
mon, the  radius  does  not  touch  the  articular  surface  of  the 
condyle,  but  the  ulna  rests  upon  the  spot  the  radius  usually 
occupies. 

The  joint  is  rigid,  and  semi-flexed,  with  the  hand  inclined 
to  pronation.  The  elbow-joint  has  an  unsightly  appearance, 
which  is  characteristic  of  the  lesion.  In  the  outwaid  disloca- 


338 


DISLOCATIONS. 


Fia.  113. 


tion  of  the  two  bones,  the  head  of  the  radius  can  be  distinctly 
felt  under  the  skin,  and  the  internal  condyle  projects  most 
strikingly,  the  epitrochlea  and  even  a  part  of  the  trod  i  lea 
being  distinctly  felt. 

If  the  lateral  displacement  be  inwards,  both  bones  of  the 
forearm  are  not  forced  completely  clear  of  the  articular  sur- 
faces of  the  lower  end  of  the  huinerus,  but  the  radius  reposes 
in  the  trochlea,  and  the  ulna  upon  the  epi- 
trochlea. In  some  cases  the  head  of  tin- 
radius  might  rest  in  front  of  the  trochlea,  or 
fall  back  into  the  olecranon  fossa.  In  all  of 
these  dislocations  much  injury  is  sustained  by 
the  ligaments,  muscles  and  nerves, — the  ulna 
nerve  being  particularly  exposed  to  bruising  or 
compressing  forces. 

Dislocation    of   both    bones  of  rhe  forearm 
forwards  has  been    denied   as  being  possible, 
unless  there  was  first  a  fracture  of  the  olecra- 
non process;  but  Velpeau,  Monin  and  Denuee. 
have  each  reported  a  case,  establishing  the  ex- 
istence of  such  an  injury,  whether  it  can  be  ac- 
counted for  or  not  by  any  process  of  reason  ing. 
In  Velpeau's  case  the  accident  occurred  by  the 
Dislocation  of  the  ra-  passage   of  a   carriage    wheel    over   the  arm. 
wards^Thetead  of  When  first  seen  by  the  surgeon,  both  bones  of 

the  radius  rests  on-     •.         /»  n  T   •       c  c   ,t        i 

the  trochlea  and  the  the  forearm  were  iouud  in  front  of  the  lower 

ulna    on    the    epi-  .  ,     ,        ,  ,  ,. 

trochlea.  extremity  ot  the  humerus,  the  radius  reposing 

in  the  coronoid  fossa,  and  the  olecranon  upon 
the  condyloid  ridge,  the  ulna  being  carried  upwards  and  a 
little  outwards.  According  to  Denuce,  the  summit  of  the 
olecranon  rests  against  the  inferior  part  of  the  trochlea  of  the 
humerus,  and  the  head  of  the  radius  is  below  and  somewhat 
separated  from  the  external  condyle ;  the  prominence  of  the 
olecranon  disappears  from  behind  the  joint,  and  on  each  side 
the  condyles  of  the  humerus  are  unusually  prominent.  The 
joint  is  rigid,  and  the  arm  is  flexed  at  least  to  a  right  angle. 
The  several  dislocations  of  the  elbo\v  are  not  always  clearly 
defined  as  distinct  displacements.  In  some  instances  the  luxa- 
tion is  partially  lateral  and  partially  backwards,  or  forward  so 
far  as  the  radius  is  concerned,  and  lateral  as  regards  the  ulna. 
In  these  extraordinary  accidents,  the  violence  is  probably  of  a 


OF  THE  RADIUS  AND  ULNA.  83!) 

twisting  nature,  or  partakes  of  complex  motions,  the  patient 
being  unable  to  define  the  cause  with  much  clearness.  A  sur- 
geon looking  on  when  the  accident  occurred,  might  not  be 
able  to  describe  how  it  was  produced. 

TREATMENT. — When  both  bones  of  the  elbow  are  dislocated, 
their  reduction  is  not  generally  attended  with  much  difficulty, 
especially  if  chloroform  be  brought  into  requisition.  In  the 
backward  dislocation,  the  surgeon  may  be  able  to  replace  the 
bones  by  placing  one  hand  against  the  forearm  near  the  elbow, 
and  pressing  with  all  his  might  while  with  the  other  hand 
grasping  the  patient's  wrist  he  emploj's  extension,  and  at  the 
same  time  uses  the  limb  as  a  lever — the  other  hand  being  a 
fulcrum — to  disengage  any  locking  of  elevations  and  depres- 
sions, and  to  force  the  bones  of  the  arm  into  their  relative 
positions.  Sir  A.  Cooper  recommended  that  the  patient  sit 
in  a  chair,  and  the  surgeon,  resting  his  foot  upon  the  edge  of 
the  seat,  places  his  knee  upon  the  inner  side  of  the  elbow- 
joint,  while  he  grasps  the  wrist  with  his  hands  ;  he  then  bends 
the  elbow  slowly,  but  forcibly  at  the  same  time  pressing  with 
his  knee  upon  the  upper  part  of  the  radius  and  ulna,  so  as  to 
disengage  their  articular  surfaces  from  the  lower  end  of  the 
humerus.  Mr.  Skey  advocates  that  one  assistant  hold  the 
upper  arm,  and  another  pull  steadily  upon  the  wrist,  and  as 
soon  as  the  coronoid  process  is  brought  below  the  level  of  the 
trochlea  of  the  humerus,  the  muscles  are  powerful  enough  to 
l)ri ng  the  bones  into  their  natural  place. 

In  those  cases  where  much  difficulty  is  experienced  in  the 
reduction,  it  is  probable  that  the  lateral  ligaments,  remaining 
untorn,  act  as  powerful  obstacles  to  a  return  of  the  bones  to 
their  normal  positions.  If  there  be  reason  to  suppose  that 
these  ligaments  oppose  reduction,  and  the  obstacles  can  not 
be  overcome  in  any  other  way,  the  joint  must  be  extended 
beyond  the  straight  attitude,  in  order  to  tear  the  most  un- 
yielding bands,  and  then  reduction  may  be  easily  effected. 

The  treatment  after  reduction  consists  in  keeping  the  arm 
in  a  sling  for  two  or  three  weeks,  and  applying  anodynes  to 
the  joint  to  suppress  high  grades  of  inflammatory  action,  each 
day  employing  passive  motion  as  a  preventive  of  anchylosis. 

It  may  be  of  importance  to  mention  that  surgeons  of  great 
experience  have  failed  to  detect  dislocation  of  both  bones  of 


340  DISLOCATIONS. 

the  forearm  backwards;  and  they  have  also  gone  through 
with  the  forms  usually  employed  to  effect  reduction,  and  sup- 
posed they  had  accomplished  their  object,  yet  have  left  the 
bones  unreduced.  If  these  mistakes  happen  to  accomplished 
surgeons,  the  inexperienced  practitioner  of  medicine  and  sur- 
gery should  be  particularly  on  his  guard  against  erroneous 
conclusions. 

If  a  mouth  or  more  has  elapsed  before  reduction  is  attempted, 
great  difficulty  will  be  encountered  in  the  endeavor  to  replace 
the  bones.  Cases  are  on  record  in  which  reduction  was  ac- 
complished after  the  displacement  had  existed  for  five  or  six 
months.  The  successful  cases  are  about  sure  to  be  reported, 
and  the  larger  proportion  of  attempts  which  turn  out  as  fail- 
ures, never  get  into  print.  Death  has  occurred  from  violent 
attempts  to  reduce  recent  and  ancient  luxations  of  the  elbow. 
However,  failures  and  unfortunate  results  should  not  deter  a 
surgeon  from  making  well  directed  efforts  in  favorable  cases 
even  if  several  months  have  elapsed  from  the  time  of  the  acci- 
dent, for  the  number  of  successful  results  is  quite  large,  estab- 
lishing the  principle  that  a  fair  trial  is  legitimate. 

In  lateral  dislocations  of  both  bones  of  the  forearm,  reduc- 
tion is  to  be  accomplished  by  extension  and  lateral  pressure, 
the  soft  tissues  being  first  relaxed  by  the  use  of  chloroform. 
If  the  luxation  be  not  purely  lateral,  but  combined  with  some 
backward  displacement,  the  restoration  of  the  bones  to  their 
proper  places  is  to  be  accomplished  by  varying-  the  direction 
of  the  forces  applied.  No  set  rules  are  applicable  for  every 
case,  consequently  the  surgeon  has  to  rely  to  a  greater  or  less 
extent  upon  his  own  ingenuity  and  resources.  My  experience 
in  treating  dislocations  of  the  elbow,  has  taught  me  that  no 
plan,  rule,  or  method,  will  invariably  prove  successful ;  but  if 
one  course  failed,  I  at  once  made  trial  of  another,  and  in  the 
end  have  always  succeeded,  except  in  one  instance  which  was 
in  trying  to  reduce  a  case  of  six  months'  standing.  I  have 
never  seen  a  dislocation  of  both  bones  forward,  but  if  I  should, 
it  seems  to  me  that  I  could  replace  the  bones  by  having  as- 
sistants make  extension  and  counter  extension  while  I  used 
the  force  of  my  hands  in  pulling  the  humerus  forwards  ;vnd 
pushing  the  forearm  backwards.  I  have  yet  to  be  convinced 
that  a  dislocated  elbow  needs  only  to  have  itsuntorn  ligaments 
relaxed  by  position  of  the  limb,  to  secure  an  easy  reduction. 


OF  THE  RADIUS.  341 

If  the  lateral  ligaments  be  lacerated  the  anterior  and  posterior 
parts  of  the  capsule  arc  too  loose  to  offer  much  resistance. 

Dislocations  of  the  elbow  should  be  reduced  as  early  as  pos- 
sible after  the  reception  of  the  injury.  If  the  bones  be  left 
displaced  for  a  number  of  clays,  the  inflammation  runs  so  high 
that  changes  of  an  unfavorable  character  take  place  in  the 
joint,  leading  sometimes  to  permanent  defects  in  the  articula- 
tion. A  luxation  of  three  weeks'  standing  is  more  difficult 
to  reduce  at  the  elbow,  than  one  of  six  weeks  at  the  shoulder. 


DISLOCATION    OF    THE     HEAD    OF    THE  RADIUS. 

The  head  of  the  radius  has  a  double  articulation,  radio- 
humeral,  and  radio-ulnar ;  atul  it  can  not  be  displaced  to  any 
great  extent  without  a  rupture  of  the  external  lateral  and  or- 
bicular ligaments,  losing  its  articular  connection  with  the  ex- 
ternal condyle  of  the  humerus,  and  the  sigmoid  notch  of  the 
ulna.  The  accident  is  one  peculiar  to  youth,  though  it  may 
occur  in  adult  life.  It  is  generally  produced  by  a  fall  upon 
the  palm  of  the  hand,  the  direction  of  the  force  acting  in  a 
manner  favorable  to  the  dislodgment  of  the  upper  end  of  the 
radius  from  its  articular  relations  ;  a  sudden  jerk  or  twist  im- 
parted to  the  hand  has  been  known  to  luxate  the  head  of  the 
radius ;  and  a  fall  or  blow  upon  the  elbow  may  displace  the 
bone.  In  one  case  that  came  under  my  observation,  the  boy 
fell  from  a  high  wall  sideways,  the  body  whirling  as  the  hand 
met  the  ground ;  in  another  case  a  boy  had  his  elbow  caught 
in  a  swinging  gate  in  such  a  way  as  to  force  the  head  of  the 
radius  from  its  normal  position  to  one  behind  the  external 
condyle  ;  and  I  have  treated  a  third  case  that  happened  in  a 
scuffle.  The  patient  said  the  other  boy  fell  on  him  while  his 
arm  was  confined  underneath  his  body. 

The  radius  may  be  displaced  forwards,  backwards,  and  di- 
rectly outwards.  The  forward  dislocation  is  far  the  most 
common  ;  the  backward  less  frequently;  and  the  outward  ex- 
ceedingly rare.  In  children  of  a  lax  condition  of  the  fibrous 
structures,  a  partial  dislocation  or  su6-luxation,  the  ligaments 
not  being  torn,  is  a  common  occurrence.  Such  a  displacement 
is  not  attended  with  pain,  the  child  throwing  the  head  of  the 
radius  into  a  state  of  deformity,  and  returning  it  again  with- 


-342 


DISLOCATIONS. 


out  any  particular  discomfort.  As  the  child  advances  in  years 
the  ligaments  increase  in  firmness,  so  that  the  defect  no  longer 
exists. 

In  the  joncard  dislocation,  the  head  of  the  radius  is  found 
in  front  of  the  external  condyle  of  the  liumerus ;  the  forearm 
is  fixed  in  a  moderately  flexed  state,  either  prone,  or  half  way 
between  pronation  and  supination.  Bending  of  the  elbow  is 
prevented  by  the  head  of  the  radius  coming  in  contact  with 
the  front  of  the  hnmerus  ;  and  complete  extension  causes 

Fia.  114. 


Dislocation  of  the  h>  ad  of  the  radius  forwards. 

pain.  The  head  of  the  radius  can  IK-  defined  in  its  new  posi- 
tion, and  when  the  hand  is  rotated,  it  can  be  seen  and  felt  to 
follow  those  movements.  The  whole  forearm  presents  a  pecu- 
liar and  characteristic  twist,  which  is  occasioned  by  the  altered 
situation  of  the  upper  end  of  the  radius.  The  tendon  of  the 
biceps  stands  prominently  forwards  in  the  bend  of  the  elbow  ; 
and  the  finger  can  be  pressed  into  a  depression  at  the  point 
vacated  by  tue  head  of  the  radius. 

The  backward  displacement  is  characterized  by  that  peculiar 
attitude  of  the  limb  which  denotes  the  nature  of  the  injury, 
though  the  position  of  the  head  of  the  radius  can  not  be  de- 
termined positively  without  careful  examination.  The  fore- 
arm is  semi-flexed,  and  held  fixed  in  a  state  of  pronation,  un- 
less the  internal  condyle  be  broken  in  the  same  accident,  which 
is  not  an  uncommon  complication.  The  head  of  the  radiu>- 


OF  THE  RADIUS. 


343 


can  be  felt  behind  the  external  condyle,  quite  superficial,  the 
linger  being  easily  pressed  into  the  cup  in  the  upper  end  of 
the  bone,  and  be  made  to  feel  the  button-like  termination 
which  plays  in  the  orbicular  ligament. 


FIG.  115. 


Dislocation  of  the  head  of  the  radius  backwards. 

Dislocation  of  the  head  of  the  radius  outwards,  must  be  a 
form  of  displacement  rarely  met,  for  there  are  only  two  or 
three  cases  reported  by  American  surgeons,  and  only  four  by 
Paul  Denuce,  who  may  not  have  been  correctly  informed  in 
regard  to  them  all.  Before  his  "Memo! re"  was  published 
( 1  s.">4)  dislocations  of  the  head  of  the  radius  were  supposed 
to  be  confined  to  the  forward  and  backward  displacements. 
It  may  even  now  be  a  question  whether  the  outward  disloca- 
tion is  not  a  modification  of  one  or  the  other  of  the  two  well 
defined  displacements  of  the  head  of  the  radius  Dr.  Willard 
Parker  reports  a  case  of  outward  dislocation  in  the  New  York 
Journal  of  Medicine  for  March,  1852,  stating  that  a  child  four 
years  old  fell  down  stairs  "  backxvardly,  with  the  right  arm 
twisted  behind  the  back,  in  such  a  position  that  the  whole 
weight  of  her  body  came  upon  her  arm." 

It  is  plain  that  the  head  of  the  radius  can  not  be  displaced 
out \vard  to  any  considerable  extent  without  a  rupture  of  the 
upper  end  of  the  interosseons  ligament,  as  well  as  a  laceration 
of  the  orbicular,  external  lateral.  a«ui  the  capsule  enclosing 
the  articulation.  A  force  competent  to  commit  that  damage. 


344  DISLOCATIONS. 

would  be  likely  to  produce  fractures  and  other  injuries  to  ad- 
joining parts. 

TREATMENT. — It  is  not  generally  a  difficult  matter  to  reduce 
dislocations  of  the  head  of  the  radius,  though  the  bone  is  not 
easily  kept  in  place  when  once  the  barriers  to  displacement 
have  been  broken  down.  A  great  many  prosecutions  to  re- 
cover damages  for  malpractice  have  grown  out  of  the  fact  that 
a  recurrence  of  the  dislocation  is  very  common.  The  non- 
professional  suppose  that  a  bone  is  not  properly  reduced  or 
skillfully  treated  after  reduction,  if  it  gets  out  of  place  in  a 
few  days  or  weeks  after  it  has  passed  through  a  surgeon's 
hands ;  and  there  are  atso  plenty  of  medical  wiseacres  who  be- 
lieve or  pretend  to  believe  about  the  same  thing.  A  few  days 
ago  a  father  brought  his  son  into  my  office,  and  asked  me  to 
examine  the  lad's  arm.  I  suspected  the  motive,  and  soon  sat- 
isfied myself  by  inquiries  that  my  suspicion  was  well  founded. 
A  physician  of  respectable  talents  had  treated  the  arm  six 
weeks  previously,  for  dislocation  of  the  head  of  the  radius  : 
in  three  weeks  from  the  accident  the  bone  was  found  to  be 
displaced,  and  the  father  then  took  the  patient  to  another 
physician,  who  said  that  the  arm  had  not  been  properly  treated, 
that  the  luxation  had  never  been  reduced.  This  statement 
made  the  parent  believe  he  had  been  imposed  upon  by  an  in- 
competent medical  attendant ;  and  he  at  once  took  steps 
toward  entering  a  suit  for  damages.  I  returned  the  bone  to 
its  natural  position,  and  bound  a  compress  in  front  of  the  head 
of  the  radius,  the  dislocation  being  forwards.  Having  assured 
the  father  that  a  dislocation  of  the  head  of  the  radius  was 
liable  to  recur,  and  that  the  physician  who  first  treated  the  in- 
jury had  probably  reduced  the  dislocation  properly,  he  went 
away  contented,  and  abandoned  his  intention  to  prosecute. 

In  a  forward  dislocation,  the  wrist  is  to  be  grasped  with  one 
hand,  and  the  elbow  with  the  other,  and  while  the  forearm  is 
moderately  flexed,  considerable  supinating  force  will  effect  re- 
duction, especially  if  the  thumb  be  used  to  push  the  head  of 
the  radius  into  position.  If  this  manoeuvre,  several  times  at- 
tempted, do  not  succeed,  powerful  extension  and  counter  ex- 
tension may  be  employed,  the  thumb  pressing  hard  upon  the 
displaced  bone.  It  is  probable  that  either  plan  would  prove 
successful  even  without  chloroform, but  if  the  patient  be  mus- 


OF  THE  RADIUS.  345 

cular  and  the  resistance  considerable,  anaesthesia  should  be 
brought  into  service. 

There  exists  some  difference  of  opinion  in  regard  to  the  at- 
titude of  the  arm  while  reduction  is  being  attempted.  Cooper 
applied  a  supinating  force  with  extension,  and  Dennce  directs 
that  the  arm  be  kept  in  a  state  of  pronation  while  extension 
is  made.  It  is  to  be  presumed,  however,  that  the  advocates 
of  several  distinct  plans  have  succeeded  in.  their  favorite 
methods;  I  am  satisfied  that  the  reduction  can  be  effected  by 
several  distinct  manoeuvres,  though  in  all  it  is  essential  that 
there  be  pressure  of  the  thumb  on  the  head  of  the  radius  to 
steady  it,  to  help  direct  it  into  place,  and  to  perform  the  part 
of  a  fulcrum  when  the  arm  is  used  as  a  lever  to  force  the  re- 
duction of  the  displaced  bone. 

In  the  backward  luxation  the  forearm  needs  flexing  and 
prouating  at  the  same  time  that  powerful  thumb  pressure  be 
brought  to  bear  upon  the  head  of  the  radius  to  force  it  into 
its  normal  position.  Gross  says  that  the  reduction  is  to  be 
effected  by  flexion  and  supination.  As  long  as  there  exist 
such  discrepancies  in  regard  to  the  direction  the  forearm  is  to 
take  in  facilitating  reduction,  it  will  be  safe  for  the  inexpe- 
rienced practitioner  to  tr}-  one  method,  and  if  that  fails,  to  re- 
sort to  another.  In  the  single  backward  dislocation  I  had  to 
treat,  I  pronated  the  hand,  and  forced  the  radius  into  place 
with  my  thumb,  the  reduction  being  accomplished  easily. 

The  outward  dislocation  needs  no  special  rules  for  its  reduc- 
tion. Extension  and  rotation  of  the  forearm  inwards  will 
place  the  bones  in  a  favorable  position, as  regards  one  another, 
for  the  pressure  of  the  thumb  or  fingers  to  return  the  bone  to 
place. 

After  the  reduction  of  either  form  of  dislocation  the  arm 
should  be  dressed  with  pasteboard  splints,  with  the  forearm 
neither  flexed  nor  extended.  Some  surgeons  employ  a  stiff 
angular  splint  to  prevent  motion  at  the  joint.  After  sufficient 
time  has  elapsed  for  the  torn  ligaments  to  heal,  the  dressings 
are  to  be  removed  and  passive  motion  instituted.  It  will  be 
well  if  the  patient  does  not  completely  flex  or  extend  the  limb 
for  several  months. 


346  DISLOCATIONS. 


DISLOCATION    OF    THE    ULNA   BACKWARDS. 

Displacement  of  the  ulna  singly  is  a  recognized  injur\ 
among  surgical  writers,  though  both  bones  of  the  forearm  are 
more  likely  to  be  dislocated  together,  than  the  ulna  alone, 
from  the  fact  that  the  radius  is  more  strongly  bound  to  the 
ulna  than  to  the  humerus.  A  force,  then,  which  is  competent 
to  luxate  the  ulna  backwards,  must  almost  of  necessity  carry 
the  radius  with  it.  In  the  few  cases  reported,  of  dislocation 
of  the  ulna  backwards,  the  radius  was  displaced  to  a  certain 
degree,  if  not  fully  luxated.  In  the  case  reported  by  Sir  Ast 
ley  Cooper,  the  radius  went  with  the  ulna  to  the  extent  of 
having  to  form  a  new  socket  for  itself  on  the  external  condyle. 

Pirrie's  Surgery  contains  a  brief  account  of  a  case  of  back- 
ward dislocation  of  the  ulna  which  occurred  in  the  practice 
of  Gosset.  Even  in  this  there  must  have  been  as  much  Ian-mi 
displacement  as  backward,  for  the  coronoid  process  lodged  on 
the  internal  condyle,  and  the  radius  may  have  been  partially 
displaced.  As  has  been  previously  stated,  in  injuries  of  the 
elbow  the  best  surgeons  may  be  deceived  in  regard  to  the 
nature  and  extent  of  a  given  lesion. 

The  signs  of  dislocation  of  the  ulna  backward  would  bo 
great  rigidity  of  the  articulatio'n,  and  a  marked  projection  of 
the  olecranon  behind  the  joint.  If  the  ulna  has  been  forced 
backwards  singly,  the  orbicular  ligament  would  have  to  be 
lacerated,  as  well  as  a  part  of  the  interosseous,  to  allow  ^the 
radius  to  remain  in  its  normal  place. 

Reduction  was  accomplished  in  Gosset's  case,  "by  extension 
and  counter-extension  applied  by  two  persons  pulling  in  oppo- 
site directions,  and  by  the  pressure  of  the  olecranon  process 
downwards  and  outwards,  while  the  forearm  was  suddenly 
flexed."  In  other  words,  the  same  method  of  reduction  \vas 
employed  as  is  commonly  recommended  to  replace  both  bones 
of  the  forearm  when  they  are  luxated  backwards. 


OF  THE  RADIUS.  347 


DISLOCATION    OF     THE    LOWER    END     OF     THE 
RADIUS   FROM    THE     ULNA. 

Hamilton,  following  Sir  A.  Cooper,  and  Malgaigne.  has 
spoken  of  forcible  separation  of  the  radius  and  ulna  at  their 
interior  articulation,  as  dislocation  of  the  lower  end  of  the 
ulna  from  the  radius;  but  in  accordance  with  the  nomencla- 
ture employed  in  describing  luxations  in  other  joints,  this  in- 
jury should  be  regarded  as  a  dislocation  of  the  radius.  The 
ulna  is  the  fixed  bone,  the  radius  moving  upon  it,  the  displace- 
ment, therefore,  is  of  the  latter  from  the  former. 

The  accident,  as  an  uncomplicated  lesion,  is  one  of  extreme 
rarity.  Sir  A.  Cooper  does  not  mention  having  met  with  a 
single  case ;  and  other  surgeons  of  the  most  extensive  expe- 
rience, have  never  seen  an  example  of  the  injury.  Malgaigne 
has  a  report  of  several  cases,  though  some  of  them  were  com- 
plicated with  fracture,  and  others  may  have  been  mistaken  for 
that  kind  of  injury. 

The  displacement  may  be. caused  by  excessive  pronation  or 
supination  of  the  hand,  as  by  wringing  clothes,  or  seizing  a 
child  by  the  hand  as  it  is  falling,  giving  the  arm  a  violent 
twist. 

The  displacement  is  accompanied  with  rupture  of  the  sacci- 
form ligament,  and  as  the  hand  goes  with  the  radius,  the  car- 
pal connection  with  the  ulna  is  broken,  allowing  the  styloid 
process  of  the  ulna  to  form  a  marked  prominence,  if  it  does 
not  actually  pierce  the  skin. 

The  displacement  may  be  forwards  or  backwards ;  the  for- 
mer is  the  most  common  accident.  In  the  forward  dislocation 
the  hand  is  held  firmly  in  a  state  of  pronation,  with  the  fingers 
somewhat  flexed  ;  the  axis  of  the  little  finger  no  longer  corre- 
sponds with  the  ulna  ;  and  the  wrist  has  a  peculiar  contorted 
appearance  not  met  in  any  other  injury. 

The  reduction  is  to  be  effected  by  extension  applied  to  the 
hand,  supinating  it  at  the  same  time.  The  radius  and  ulna 
must  also  be  pressed  into  their  natural  relations  with  each 
other,  while  the  extending  and  supinating  forces  are  applied. 

In  the  bnckirartl  dislocation  the  signs  of  the  displacement 
are  in  some  respects  the  reverse  of  those  in  the  other  variety 
of  luxation  ;  the  hand  is  powerfully  supinated,  the  fingers 


348  DISLOCATIONS. 

being  moderately  flexed,  and  the  wrist  having  a  peculiar  twist 
in  it  which  is  not  a  deformity  belonging  to  a  fracture. 

The  reduction  is  to  be  accomplished  by  extension  and  pro- 
nation  exerted  upon  the  hand,  while  an  effort  is  made  to  piv-s 
the  two  bones  into  their  normal  relations  with  each  other. 

As  there  is  great  liability  to  a  recurrence  of  either  form  of 
luxation,  while  the  torn  ligaments  remain  ununited,  the  fore- 
arm and  hand  should  be  dressed  with  the  same  appliance  re- 
commended for  the  treatment,  of  a  fracture  through  the  lower 
extremity  of  the  radius.  The  dressing  should  be  worn  for 
two  or  three  weeks,  and  then  the  arm  ought  not  to  be  sub- 
jected to  pronating  and  supinating  forces  for  six  or  eight 
weeks  more. 

In  a  cas-e  of  alleged  malpractice  that  never  came  to  trial,  I 
had  an  opportunity  to  see  how  medical  men  of  considerable 
experience  will  differ  in  regard  to  the  nature  of  a  surgical 
injury.  The  defendant  in  the  case  was  charged  with  not 
bavin"-  discovered  and  treated  a  dislocation  of  the  ulna  from 

O 

the  radius,  the  allegation  being  that  the  young  woman  was 
seriously  damaged  by  said  neglect.  The  prosecutrix  had  been 
thrown  from  a  wagon,  and  in  the  fall  sustained  an  injury  of 
the  Avrist.  The  phvsician  having  the  case  in  charge  did  not 

A       •/  o  ~ 

discover  a  lesion  beyond  that  of  a  sprain,  and  applied  a  band- 
age to  the  hand  and  wrist,  and  ordered  -arnica  applications. 
In  the  course  of  a  few  months  a  peculiar  and  marked  laxity 
of  the  ligaments  of  the  wrist  came  on,  so  that  the  patient 
<3ould  voluntarily  make  an  awkward  deformity  at  that  joint. 
In  some  of  these  forced  attitudes  or  positions,  the  limb  ap- 
peared as  if  the  hand  and  radius  had  been  forcibly  separated 
from  the  ulna,  or  that  the  ulna  had  been  torn  loose  from  the 
radius,  hence  the  charge  of  malpractice.  Before  the  trial 
came  off  the  girl  saw  several  eminent  surgeons  in  the  coun- 
try, and  all  advised  her  to  drop  the  suit  on  the  ground  that 
no  real  luxation  existed,  but  that  her  wrist  had  been  so  injured 
that  the  soft  tissues,  especially  the  ligaments,  were  rendered 
unnaturally  pliant  or  yielding;  that  loose  joints  in  any  part 
of  the  body  were  not  uncommon,  particularly  in  the  young. 
There  was  evidently  an  hysterical  complication  which  in  sonic 
instances  will  produce  queer  conditions  of  the  body. 

Six  physicians  of  the  place  were  ready  to  swear 'that  dislo- 
cation existed,  but  the  limb  at  length  became  as  useful  as  the 
other,  and  scarcely  more  deformed. 


CHAPTER  IX. 
DISLOCATION    OF    THE    WRIST 


The  older  surgical  writers,  back  to  the  time  of  Hippocrates, 
regarded  dislocation  of  the  hand  or  carpus  from  the  lower 
end  of  the  radius  and  ulna,  as  an  accident  of  frequent  occur- 
rence, but  within  fifty  years  it  has  been  ascertained  that  the 
injury  is  exceedingly  rare,  and  that  most  of  those  lesions  once 
regarded  as  dislocations  are  now  presumed  to  have  been  frac- 
tures of  the  lower  extremity  of  the  radius.  This  error  of 
diagnosis  was  suspected  by  Pouteau,  and  positively  avowed 
by  Dupuytren  who  gave  the  subject  great  attention.  It  is  a 
matter  of  no  little  surprise  that  the  surgeons  of  a  century  ago 
so  often  met  with  dislocations  of  the  wrist,  and  that  Dupuy- 
tren and  his  followers  should  have  found  so  few.  Although 
it  is  quite  evident  that  fractures  of  the  inferior  extremity  of 
the  radius  were  once  thought  to  be  luxations  of  the  wrist,  the 
bold  assumptions  of  Dupnytren  have  not  been  fully  sustained 
by  critical  observers  of  more  recent  times.  Dislocation  of  the 
carpus  upon  the  radius  and  ulna  is  undoubtedly  a  rare  form 
of  accident,  yet  the  lesion  is  proved  by  dissection  to  have  had 
an  existence.  In  some  instances  the  dislocation  has  been 
compound,  andnn  others  it  is  complicated  with  fracture  of  the 
rim  of  the  articular  cavity  at  the  lower  extremity  of  the 
radius. 

The  displacement  may  be  in  either  of  two  directions,  back- 
wards or  forwards.  In  the  former  variety  the  carpus  is  thrown 
upon  the  dorsum  of  the  wrist,  and  the  ends  of  the  radius  and 
ulna  form  an  abrupt  prominence  on  the  palmar  aspect  of  the 
carpus.  The  general  aspect  of  the  wrist  is  that  of  fracture 
of  the  radius,  yet  a  careful  examination  of  the  parts  will  de- 
termine the  difference  between  the  two  injuries.  In  fracture 
of  the  radius  the  deformity  can  be  mostly  overcome  by  seizing 

(349) 


350  DlSUM'  ATIuXS. 

the  hand  and  making  extension,  and  when  this  force  is  re- 
moved and  the  limb  is  left  to  itself  unconstrained,  the  defor- 
mity at  once  returns ;  in  dislocation  of  the  wrist  backwards, 

FIG.  116. 


Dislocation  of  the  carpus  backwards. 

great  reducing  power  is  required  to  restore  the  parts  to  their 
normal  places,  and  when  once  reduced  they  will  stay  in  plai-r. 

In  September,  1863,  Peter  Sullivan,  a  laborer,  while  exca- 
vating a  bank  of  earth  in  the  vicinity  of  the  city,  fell  from  a 
ledge  six  or  eight  feet  in  height,  and  struck  on  tlie  knuckles 
of  his  right  hand  which  grasped  the  bowl  of  a  large  briarwood 
pipe.  He  sustained  a  severe  injury  of  the  wrist,  compelling 
him  to  abandon  his  work  and  come  to  the  city  for  surgical 
attention.  He  walked  to  the  street  railroad  and  then  rode  to 
my  office.  I  found  the  wrist  appearing  much  as  it  does  in 
fracture  near  the  lower  extremity  af  the  radius,  though  with 
sufficient  difference  in  several,  respects  to  institute  a  more 
thorough  investigation  of  the  lesion.  The  wrist  was  too  rigid 
for  fracture,  the  elevation  on  the  back  of  the  wrist  was  too 
abrupt  for  the  usual  dorsal  tumor  attending  a  broken  radius, 
and  the  palmar  lump  was  too  near  the  hand.  The  lingers 
were  flexed;  and  the  styloid  processes  of  the  radius  and  ulna 
could  be  felt  occupying  the  same  plane,  which  is  not  the  case 
in  fracture.  The  arm  just  above  the  dorsal  tumor  maintained 
its  usual  width  and  flatness,  and  was  not  rounded  as  it  is  found 
after  fracture  of  the  radius  through  its  lower  extremity. 

I  attempted  to  reduce  the  dislocation,  for  such  it  was.  In- 
taking  the  patient's  hand  in  mine,  and  making  extension  ;  but 
he  complained  so  much  of  pain  as  soon  as  I  used  any  force, 
that  I  administered  to  him  enough  chloroform  to  deaden  his 
sensibilities  and  to  relax  his  muscles  to  some  extent.  I  llnin 


OP  THE  WHIST.  851 

made  extension  with  one  hand-,  first  flexing  the  wrist  a  little 
to  get  the  thumb  of  the  other  hand  so  it  could  both  act  as  a 
fulcrum  as  I  applied  extension  and  push  the  carpus  iorward 
into  its  relative  position  with  the  radius  and  ulna.  1  had  to 
use  considerable  force  to  effect  reduction  which  was  an- 
nounced by  an  audible  snap.  I  then  dressed  the  wrist  in  a 
bandage  for  a  few  da}Ts,  when  the  patient  claimed  to  be  well, 
and  1  lost  sight  of  him.  In  this  case  I  endeavored  to  ascer- 
tain whether  the  muscles  or  the  untorn  ligaments  opposed  re- 
duction ;  and  could  not  solve  the  question,  though  it  seemed 
to  me  that  the  tendons  and  their  sheaths  offered  the  greatest 
obstacles. 

A  dislocation  of  the  carpal  bones  forwards  is  an  injury  more 
seldom  met  thmi  the  backward  displacement.  The  accident 
is  produced  by  falls,  the  hand  so  striking  as  to  force  it  into 
extreme  extension.  The  displacement  is  easily  recognized 
by  the  character  of  the  deformity.  The  lower  extremities  of 
the  radius  and  ulna  form  a  well  marked  projection  back  wards 

FIG.  117. 


Dislocation  of  the  carpus  forwards. 

and  the  carpus  forwards.  The  stj'loid  processes  of  the  two 
forearm  bones  are  so  prominent  and  well  defined  that  no  mis- 
take could  be  made  in  regard  to  the  nature  of  the  injury. 
The  wrist  and  hand  are  rigidly  stiff,  and  can  not  be  made  to 
assume  their  natural  relation  in  regard  to  the  forearm,  as  in 
case  of  fracture. 

There  are  some  congenital  defects  of  the  wrist  which  present 
the  appearances  of  dislocation,  but  they  are  quite  different 
from  an  ordinary  luxation  produced  suddenly  by  violence. 

Reduction  of  a  dislocation  of  the  carpus  forwards  is  to  be 
produced  by  bending  the  hand  a  little  more  backward  so  as  to 
place  the  thumb  well  against  it  in  the  capacity  of  a  fulcrum 
and  to  help  press  the  bones  into  place  when  extension  is  made 


352  DISLOCATIONS. 

by  the  surgeon,  grasping  the  patient's  hand  in  his  own  and 
making  powerful  extension.  After  reduction  is  accomplished 
the  wrist  may  he  treated  to  a  cooling  and  anodyne  lotion,  and 
used  with  care  until  the  lacerated  ligaments  are  healed. 


DISLOCATION  OF  THE  BOXES  OF  THE  CARPUS 
FROM  ONE  ANOTHER. 

There  is  a  popular  notion  that  some  of  "  the  little  hones  in 
the  wrist "  may  get  out  of  place ;  and  in  fact,  it  has  been 
shown  by  dissection  that  the  carpal  bones  may  be  displaced. 
The  head  of  the  os  magnum,  suft'ers  a  partial  luxation  from 
the  cavity  formed  for  it  by  the  scaphoid  and  semi-lunar  bones. 
The  displacement,  observed  mostly  in  females  of  a  lax  condi- 
tion of  the  ligaments,  is  caused  by  forced  flexion  of  the  wrist. 
either  in  falls,  or  from  accidents  in  which  a  severe  twist  is 
given  to  the  hand  and  wrist.  The  nature  of  the  injury  is  re- 
cognized by  an  unnatural  projection  on  the  dorsum  of  the 
carpus,  which  increases  when  the  wrist  is  flexed,  and  dimin- 
ished when  it  is  extended. 

The  reduction  can  generally  be  effected  by  pressure  upon 
the  tumor,  especially  if  extension  be  made  at  the  same  time 
upon  the  fore-  and  middle-fingers.  When  once  reduced  the 
bone  should  be  held  in  place  by  a  compress  and  bandage. 

Richerand  once  met  with  a  luxation  of  the  os  magnum 
which  happened  to  a  woman  in  the  throes  of  labor.  She 
seized  the  edge  of  her  mattress  and  squeezed  it  forcibly,  turn- 
ing her  wrist  forwards.  She  heard  something  snap,  and  a 
tumor  immediately  formed  on  the  back  of  her  wrist,  which 
gave  her  great  pain.  The  extended  hand  showed  no  defor- 
mity, and  the  difficulty  never  received  any  treatment.  Cho- 
part  reports  having  seen  a  similar  case ;  and  Bransby  Cooper 
says  :  "  I  have  known  the  os  magnum  to  be  dislocated  back- 
wards from  its  articulation  with  the  scaphoid  and  lunar  bones. 
The  subject  of  this  accident  was  a  carpenter,  an  out-patient 
of  my  colleague,  Mr.  Callaway.  In  this  case,  the  appearan  ;e 
was  that  of  a  hard  fixed  tumor  on  the  dorsal  surface  of  the 
carpus:  the  man  described  the  injury  to  have  been  originally 
caused  three  years  before,  by  a  very  forcible  grasping  exertion 
of  the  hand.  The  displacement  frequently  recurred,  and  he 


OF  THE  WHIST.  358 

could  generally  slip  the  bone  back  into  its  place  by  pressure 
of  the  thumb." 

Similar  dislocations  of  some  of  the  other  carpal  bones  have 
been  recorded.  Erichsen  mentions  having  seen  dislocations 
of  the  semilunar  and  pisiform  bone.  The  latter  was  displaced 
by  an  effort  to  lift  a  heavy  weight,  and  the  bone  was  drawn  up 
the  arm  to  the  distance  of  nearly  an  inch  b}"  the  flexor  carpi 
ulnaris. 

A  case  is  reported  by  Maisonneuve,  of  simple  dislocation 
backwards  of  the  second  row  of  carpal  bones  from  the  first, 
caused  hy  a  fall  from  a  height  of  forty  feet.  The  nature  of 
the  injury  was  verified  by  dissection. 

The  different  bones  of  the  carpus  are  so  firmly  bound  together 
with  ligaments,  and  so  strongly  held  in  place  by  passing  ten- 
dons, that  no  ordinary  accident  is  likely  to  displace  one  or 
more  of  them.  A  blow  of  the  nature  of  a  driven  punch,  and 
a  gunshot  wound,  very  frequently  displace  these  bones,  but 
the  nature  of  the  injury  differs  essentially  from  ordinary  dis- 
locations, and  has  ilo  claims  to  be  considered  in  this  connection. 


DISLOCATION   OF    THE   METACARPAL   BONES. 

Displacement  of  the  metacarpal  bone  of  the  thumb  from  the 
os  trapezium,  either  forwards  or  backwards,  is  possible,  though 
the  injury  is  not  common.  The  backward  luxation  is  the 
most  frequent,  and  is  caused  by  a  fall  upon  the  thumb, 
throwing  it  into  a  state  of  extreme  flexion.  The  forward  dis- 
location may  be  caused  by  a  force  throwing  the  thumb  vio- 
lently backward,  or  by  direct  violence.  In  a  case  coming 
under  my  observation  the  displacement  was  caused  by  the  fall 
of  a  heavy  rock  which  struck  the  metacarpal  bone  of  the 
thumb  near  its  carpal  extremity,  and  forced  it  inwards  or  for- 
wards. The  soft  tissues  covering  the  bone  at  the  seat  of  in- 
jury were  severely  bruised,  but  the  dislocation  wras  not  thus 
rendered  compound.  The  injury  was  recognized  by  pressing 
the  fingers  into  the  depression  caused  by  the  displacement, 
and  by  other  ordinary  signs  of  luxation.  Chloroform  was 
administered,  when  by  extension  and  pressure  in  the  hollow 
of  the  hand  against  the  projecting  bone  in  that  region,  the 
reduction  was  accomplished.  The  backward  luxation  is  the 
23 


354:  DISLOCATIONS. 

easiest  to  reduce,  though  the  assistance  of  anaesthesia  may  be 
needed  in  successful  attempts  to  reduce  either  form  of  the 
injury. 

Malgaigue  has  collected  accounts  of  dislocations  which  hap- 
pened to  three  other  of  the  metacarpal  bones.  In  one  of  them, 
Bourguet's  case,  the  carpal  extremity  of  the  metacarpal  bone 
of  the  index  finger  was  displaced  forwards  by  a  great  and 
sudden  force  being  applied  to  the  back  of  the  hand.  A  great 
depression  at  the  point  of  luxation  indicated  the  nature  of  the 
injury.  Reduction  was  effected  by  extension  applied  to  the 
finger  and  pressure  made  in  the  palm  near  the  thumb.  In  the 
case  seen  by  Roux,  there  was  a  backward  luxation  of  the  me- 
tacarpal bone  of  the  great  finger.  The  accident  happened  in 
a  mine,  from  the  explosion  of  blasting  powder.  The  promi- 
nence of  the  bone  oirthe  dorsum  of  the  hand  indicated  the 
nature  of  the  difficulty.  Reduction  was  effected  by  extension, 
and  pressure  on  the  displaced  bone.  There  was  always  a 
tendency  to  reluxation  when  the  hand  was  straightened. 
Hamilton  mentions  having  seen  one  case  of  luxation  of  the 
metacarpal  bones  of  the  index  and  great  fingers,  the  accident 
being  caused  by  a  blow  given  with  the  fist  or  clenched  hand. 
It  was  an  old  case,  the  bones  becoming  reluxated  after  having 
been  reduced. 

The  carpo- metacarpal  articulation  of  the  thumb  closely  re- 
sembles a  ball  and  socket  joint,  hence  a  luxation  would  have 
to  be  managed  on  principles  that  govern  the  overcoming  of 
dislocations  of  the  shoulder  and  hip.  In  other  words,  the 
articular  head  of  the  bone  would  be  forced  through  a  rent  iji 
the  capsnlar  ligament;  and  a  return  of  the  bone  must  bo 
through  the  aperture  of  escape.  The  reduction  is  not  to  bo 
brought  about  by  forcible  extension  and  counter-extension, 
but  by  the  manoeuvre  of  placing  the  thumb  in  the  attitude  it 
assumed  when  luxation  occurred,  and  then  prying  the  head 
of  the  bone  into  place,  the  operator's  thumb  boing  used  as  a 
moving  or  sliding  fulcrum  in  the  application  of  forces.  And 
because  the  leverage  is  so  restricted  it  is  not  easy  to  overcome 
this  dislocation.  In  fact,  the  feat  is  nearly  impossible  unless 
the  patient  be  put  under  the  influence  of  an  anaesthetic. 


CHAPTER    X. 
DISLOCATION  OF  THE  PHALANGES. 


DISLOCATION  OP  THE  FIRST  PHALANX  OF  THE  THUMB. — This 
injury  is  of  frequent  occurrence  ;  especially  the  backward  dis- 
placement, the  end  of  the  first  phalanx  being  thrown  upon 
the  extremity  of  the  metacarpal  bone.  The  cause  is  generally 
u  fall  upon  the  end  of  the  thumb,  or  upon  the  last  knuckle  of 
that  digit.  The  symptoms  are  so  distinctly  marked  that  there 
is  no  danger  of  error  in  the  diagnosis.  The  pain  is  great ; 
there  is  inability  to  move  the  joints  of  the  thumb  ;  and  the 
bones  being  sparsely  covered,  the  displacement  becomes 
strikingly  apparent. 

The  reduction  is  not  difficult,  though  the  older  surgical 
writers  speak  of  subcutaneously  dividing  the  lateral  ligaments 
of  the  joint,  and  the  tendons  of  the  flexor  muscles.  I  have 
reduced  this  dislocation  several  times,  and  have  never  found 

FIG.  118. 


Dislocation  of  the  first  phalanx  of  the  thumb  forwards. 


any  serious  trouble  in  the  operation.  In  either  form  of  dis- 
placement I  extend  or  flex  the  luxated  digit  to  get  my  own 
thumb  well  placed  against  the  end  of  the  dislocated  bone, 
then  I  make  extension  and  at  the  same  time  push  thephalanx 
into  place.  I  have  never  yet  met  a  case  that  required  the  use 
of  a  tape,  or  other  appliance  to  fasten  upon  the  thumb,' as  a 

(355) 


350  DISLOCATIONS. 

means  of  obtaining  a  better  hold  for  the  purpose  of  making 
extension. 

Mr.  Flower  says  :  "  After  a  fair  trial  of  all  the  above  mea- 
sures, reduction  has  still  been  unaccomplished  in  so  manv 
cases,  that  both  the  cause  of  the  difficulty  and  the  means  by 
which  it  ought  to  be  overcome,  have  become  a  standard  sub- 
ject for  research  and  speculation  among  surgeons  of  all  coun- 
tries. Although  much  difference  of  opinion  lias  certainly  ex- 
isted upon  this  point,  the  majority  of  writers  have  agreed  that 
the  flexor  brevis  pollicis  muscle  is  in  some  way  the  chief  ob- 
stacle to  reduction.  Dissection  of  dislocations  artificially  pro- 
duced upon  the  dead  subject,  shows  that  when  the  phalanx  is 
completely  carried  on  to  the  dorsal  surface  of  the  metacarpal 
bone,  the  two  attachments  of  the  flexor  brevis,  with  their  con- 
tained sesamoid  bones,  slip  over  its  wide  head,  and  tightly 
embrace  its  neck.  It  is  evident  that  the  bone  can  only  be  dis- 
engaged from  this  situation  with  difficulty.  The  only  success- 
ful way  hitherto  devised  to  overcome  this,  is  the  subcutaneous 
section  of  one,  or  even  both  of  the  tendons  of  the  muscle. 
The  cause  of  occasional  failure  of  even  this  somewhat  severe 
proceeding  is,  I  believe,  the  difficulty  of  effecting  a  complete 
division  of  all  the  opposing  fibres.  I  have  found,  in  the  dead 
subject,  that  a  division  of  the  fascia  which  connects  together 
the  two  sesamoid  bones,  by  allowing  the  tendons  to  separate 
from  each  other,  quite  up  to  their  insertion,  materially  facili- 
tates reduction,  without  resorting  to  the  section  of  the  muscle 
itself;  but  I  have  not  yet  had  an  opportunity  of  trying  this 
on  the  living."  Dr.  Humphrey,  also  on  anatomical  grounds, 
recommends  an  endeavor  to  draw  the  sesamoid  bones  for- 
wards, by  means  of  blunt  hooks  inserted  through  an  incision 
in  the  skin. 

Hamilton  failed  in  one  case  to  effect  reduction,  though  he 
used  chloroform,  and  the  "Indian  puzzle."  The  parents  of 
the  girl  would  not  allow  the  flexor  tendons  and  lateral  ligaments 
to  be  divided,  so  the  patient  had  to  go  with  the  thumb  still 
dislocated.  If  a  surgeon  of  his  ability  and  experience  failed 
to  effect  reduction,  there  are  occasionally  cases  that  will  baffle 
the  skill  of  the  most  expert. 

I  hold  to  the  opinion  that  there  is  something  radically 
wrong  in  the  usual  manner  of  applying  the  reducing  forces 
The  dorsal  dislocation  is  produced  by  forced  flexion  of  the 


OF  THE  PHALANGES.  357 

thumb  ;  and  u*  soon  us  the  displacement  occurs,  the  digit  re- 
turns part  way  from  this  extreme  flexion.  Now,  in  a  rational 
attempt  at  reduction,  the  thumh  should  be  carried  to  the  ex- 
treme point  of  flexion,  and  the  thumb  of  the  surgeon  should 
then  hold  the  displaced  bone  so  it  can  not  slip  when  the 
patient's  thumb  is  extended.  It  is  clear  that  by  this  manceuvre 
the  surgeon's  thumb  acts  the  part  of  a  fulcrum,  while  the 
patient's  digit  is  employed  as  a  lever  to  pry  the  dislocated  bone 
into  place.  In  the  palmar  dislocation,  the  reverse  of  the  above 
movements  should  be  followed.  Dislocation  takes  place  from 
forced  extension,  and  then  the  thumb  falls  back  towards  its 
normal  attitude  ;  reduction,  therefore,  is  to  be  accomplished 
by  tilting  the  digit  backwards  to  the  point  it  was  forced  to 
assume  before  luxation  occurred,  and  then  the  displaced  end 
of  the  phalanx  being  held  rigidly  while  flexion  is  made,  suc- 
cess attends  the  manoeuvre.  At  least  the  plan  is  right,  and  if 
it  fail  once  it  may  be  tried  again,  and  repeated  until  the  re- 
duction is  accomplished. 

DISLOCATIONS  OF  THE  FIRST  PHALANGES  OF  THE  FINGERS. — 
The  first  phalanx  of  the  index  and  little  fingers  are  more  fre- 
quently luxated  than  the  corresponding  bones  of  the  great  and 
ring  fingers.  The  more  exposed  positions  of  these  digits  con- 
tribute to  the  frequency  of  the  accident,  though  such  lesions 
are  quite  rare.  I  have  seen  a  forward  dislocation  of  the  fore- 
finger, which  was  caused  by  the  digit  being  caught  in  a  cog- 
wheel ;  and  a  dislocation  of  the  little  finger  backwards,  which 
was  produced  by  the  explosion  of  powder  in  a  flask.  The 
deformity  in  both  cases  was  quite  distinct,  especially  in  the 
little  finger.  The  abrupt  projection  of  the  displaced  bone  was 
distinctly  seen  and  felt.  In  the  forefinger  the  nature  of  the 
injury  was  not  so  apparent,  though  by  a  little  manipulation 
the  displacement  became  too  evident  to  be  mistaken. 

The  reduction  was  effected  by  extension  and  a  pushing  of 
the  bones  into  place,  the  luxation  being  managed  on  the  plan 
of  first,  tilting  the  luxated  digit  backwards  in  the  forward  dis- 
placement, and  forwards  in  the  backward  displacement,  the 
reason  for  which  being  already  given  in  the  directions  for  re- 
ducing the  first  phalanx  of  the  thumb. 

Dislocation  of  the  terminal  phalanx  of  the  thumb,  or  of  the 
second  and  third  phalanges  of  the  fingers,  is  an  accident  easily 
recognized.  Falls  or  blows  upon  the  ends  of  the  digits  com- 


358  DISLOCATIONS. 

monly  produce  tlte  displacement.  The  reduction  would  be 
reasonably  easy  if  a  firm  hold  were  practicable.  Although 
the  "  Indian  puzzle,"  a  cylinder  of  basket-work,  made  to  ap- 
pear like  a  snake  in  the  act  of  swallowing  the  finger,  is  highly 
recommended  to  secure  a  fastening,  yet  I  have  had  no  occa- 
sion to  use  the  cunningly  devised  toy  for  the  purpose  of  ap- 
plying adequate  extension.  The  strength  of  my  own  finger* 
has  thus  far  proved  sufficient  to  effect  reduction. 

The  violence  done  to  the  digital  articulations  in  cases  of 
dislocation,  is  apt  to  be  followed  by  a  high  degree  of  inflam- 
mation, endangering  the  condition  of  anchylosis.  Tu  rare  in- 
stances, complicated  with  severe  injuries  to  the  joint,  and  its 
investing  tissues,  it  maybe  best  to  amputate,  to  avoid  tetanus 
and  other  serious  complications. 

The  game  of  base-ball  has  greatly  increased  the  number  of 
phalangeal  luxations.  Such  extreme  exertion  is  given  to  the 
.act  of  catching  a  hard,  heavy,  and  swiftly  moving  hall,  that 
injuries  to  the  fingers  are  not  thought  of,  hence  the  frequency 
of  digital  dislocations.  And  the  lesion  is  frequently  of  the 
compound  character,  therefore  the  more  serious.  The  luxa- 
tion is  commonly  produced  by  the  ball  being  received  on  the 
end  of  the  finger  extended  to  guide  the  missile  into  the  hol- 
low of  the  hand.  The  injury  may  occur  at  either  of  the  pha- 
langeal joints,  and  at  the  metacarpo-phalangeal  articulations. 
The  displacement  is  attended  with  keen  pain,  yet  excited 
players  have  been  known  to  keep  on  with  the  game  after  a 
dislocation  had  been  sustained. 

In  the  management  of  a  dislocated  finger  after  reduction 
has  been  effected,  little  need  be  advised  except  that  the  injured 
digit  be  allowed  to  rest  a  few  days  under  cooling  lotions,  and 
then  begin  passive  motion  to  prevent  anchylosis.  In  most 
instances,  unless  the  cartilages  be  crushed,  the  injury  will  be 
overcome  without  permanent  stiffness. 

It  may  be  well  to  remark  that  if  anchylosis  must  take 
place,  the  finger  should  be  kept  in  a  partially  flexed  state.  A 
stiff  finger  in  an  extended  or  straight  attitude  is  an  awkward 
affair. 


CHAPTER  XI. 


Powerful  forces  are  often  brought  to  bear  on  the  shaft  of 
the  femur  as  a  lever  to  dislodge  the  head  of  the  bone  from  its 
deep  socket.  The  capsule  of  the  joint  is  strong,  and  its  an- 
terior and  inferior  aspects  are  strengthened  by  that  aggrega- 
tion or  reinforcement  of  fibres,  called  the  ilio-femoral  ligament, 
to  say  nothing  of  the  protecting  influences  of  the  ligamentum 
teres  and  the  cotyloid  ligament. 

According  to  the  statistics  of  Malgaigne,  collected  at  the 
Hotel  Dieu,  the  hip  stands  next  to  the  shoulder  in  the  relative 
frequency  of  displacements. 

There  were,  of  491  cases  of  dislocation, — of  the 


Shoulder 321 

Hip 34 


Clavicle 33 

Eitiow 26 

Foot 20 

Thumb IT 


Fingers -.7 

Jaw....  7 


Knee ...6 

Rtvlins 4 

Patella 3 

Spine 1 


These  tables  show  that  about  ten  dislocations  occur  at  the 
shoulder-joint  where  one  happens  to  the  hip,  yet  the  latter 
articulation  is  more  frequently  luxated  than  the  thumb  or  jaw 
which  are  generally  supposed  to  be  specially  liable  to  such 
accidents.  It  is  possible  that  the  statistics  of  Malgaigne  do 
not  justly  represent  the  relative  liability  of  each  joint  to  lux- 
ation ;  yet  tables  collected  in  other  Hospitals  show  that  the 
hip-joint  is  one  which  often  suiters  luxation. 

The  lesion  is  more  common  to  men  than  women,  for  the 
obvious  reason  that  males  are  most  exposed  to  such  violence 
a>  produces  these  graver  accidents  of  life;  and  the  injury  is 
mostly  confined  to  ages  ranging  from  twenty  to  forty-five, 
embracing  a.  period  of  life,  devoted  to  enterprises  fraught  with 
dauber.  The  earliest  recorded  au'c  at  which  dislocation  at  the 

(359) 


860  DISLOCATIONS. 

hip  has  occurred,  is  eighteen  mouths,  and  the  oldest,  eighty- 
six  years.  During  childhood  a  force  competent  to  dislocate 
the  femur  would  be  more  apt  to  separate  the  epiphyses  of  the 
bone  ;  and  after  the  age  of  fifty,  the  bones  become  so  brittle 
that  fracture  of  the  neck  of  the  femur  is  more  liable  to  occur 
than  displacement  of  the  head  of  the  bone  from  the  aeetabu- 
lar  cavity. 

Much  has  been  written  concerning  spontaneous  dislocation 
of  the  hip  arising  from  disease  of  the  joint  during  early  life, 
but  complete  luxations  from  such  a  cause  must  be  exceedingly 
rare  ;  and  they  are  of  a  nature  not  to  be  considered  in  this 
connection.  According  to  Cooper,  persons  have  existed  who 
possessed  the  power  of  voluntarily  dislocating  their  hip,  and 
again  reducing  it.  Paralysis  of  the  muscles  on  one  side  of 
the  joint,  has  been  known  to  effect  dislocation  in  the  opposite 
direction. 

Dislocation  of  the  coxo-femoral  articulation  resulting  from 
violence,  may  occur  in  four  directions : 

1st.  The  head  of  the  bone  may  be  forced  upwards,  and 
more  or  less  backwards,  upon  the  dorsum  ilii. 

2d.  Far  backwards,  and  slightly  upwards,  into  the  great 
ischiatic  notch.  This  is  really  a  modification  of  the  preceding 
and  not  a  distinct  form  of  luxation. 

3d.  Downwards  and  inwards,  into  the  obturator  foramen. 

4th.  Upwards  and  inwards,  upon  the  body  of  the  pubes. 

These  last  two  displacements  belong  to  one  form,  viz.,  the 
dislocation  inwards,  the  range  upwards  to  the  pubes,  and 
downwards  to  the  thyroid  foramen  depending  much  upon  the 
direction  of  the  force  received,  or  some  modifying  circum- 
stance. The  same  observation  may  be  made  concerning  the 
first  two  mentioned  forms  of  displacement,  it  being  positively 
known  that  the  head  of  the  bone  may  occupy  both  positions 
in  a  single  accident,  or  during  attempts  at  reduction.  There 
is  no  precise  spot  where  the  head  of  the  bone  always  rests 
when  dislocated,  but  a  wide  range  is  given  to  the  position  oc- 
cupied. The  different  attitudes  assumed  by  the  toes  and  foot 
in  different  cases  clearly  indicate  that  the  head  of  the  femur 
is  subject  to  considerable  variety  of  position. 

Thej'elative  proportion  of  the  different  varieties  of  displace- 
ment, is,  according  to  Sir  A.  Cooper,  the  following:  in  twenty 
cases  of  all  kinds,  there  will  he  twelve  on  the  dorsum  ilii, five 


OF  THE  FK.MUR. 


361 


110. 


into  the  ischiatic  notcli,  two  into  the  obturator  foramen,  and 
one  on  tlie  pubes.  Or,  considering  only  two  varieties  of  dis- 
placement, there  will  be  seventeen  backwards,  and  three  for- 
wards, showing  a  vast  preponderance  in  the  backward  direc- 
tion. In  seventeen  cases  observed  by  Malgaigne,  eleven  were 
either  iliac  or  ischiatic,  four  pubic,  and  two  obturator,  or 
eleven  hack  wards  and  six  forwards.  Of  the  104  cases  col- 
lected by  Hamilton,  eighty-three  were  backwards,  and  twen- 
ty-one forwards,  or  in  the  ratio  of  four  in  the  former  direction 
to  one  in  the  latter. 

BACKWARD  AND  UPWARD  DISLOCATION. — In  the  common  dis- 
location backwards,  the  head  of  the  femur  wholly  leaves  the 
articulation,  and  takes  a  position  on  the  outside  of  the  socket, 
resting  on  the  dorsum  of  the  ilium,  or  between  the  glutens 
maximus  and  medius,  or  as  far  back  as  the  pyriforrnis  mus- 
cles. The  great  displacement  necessitates  the  rupture  of  the 
teres  and  capsular  ligaments.  The  small  rotator  muscles  are 

put  greatly  on  the  stretch,  or  ar.e 
more  or  less  lacerated.  The  lux- 
ation is  attended  with  consider- 
able effusion  of  blood  in  and 
about  the  joint,  and  the  parts 
implicated  in  the  injury  are  apt 
to  bear  marks  of  violence. 

The  sym/)to)/ts  of  the  disloca- 
tion are,  strongly  marked,  and 
characteristic  of  the  injury  :  the 
limb  is  shortened  from  one  to 
three  inches,  commonly  from  an 
inch  and  a  half  to  two  inches  ; 
it  is  inverted,  slightly  flexed,  and 
inclined  forwards  and  inwards, 
the  toes  resting  on  the  opposite 
foot  near  the  ankle;  the  great 
trochanter  is  tilted  forwards, 
giving  a  full  appearance  over 
and  just  above  the  acetabulum,  and  the  head  of  the  femur, 
in  thin  persons,  can  be  felt  beneath  its  gluteal  covering,  in  its 
new  position.  The  limb  is  rigid,  and  can  not  be  elongated, 
extended,  or  abducted  without  great  pain  :  it  may  be  Hexed, 
adducted,  and  rotated  inwards,  in  a  moderate  degree,  without 


Dislocation  of  the  head  of  the  femur  up- 
wards mill  backwards,  upon  the  dorsum 
of  the  ilium. 


362  DISLOCATIONS. 

creating  much  distress.  It  is  useful  iu  determining  the  posi- 
tion of  the  head  of  the  bone,  to  have  the  patient  take  the 
erect  attitude,  standing  on  the  sound  limb.  The  great  toe  of 
the  luxated  limb  will  then  approach  the  instep  of  the  opposite 
foot,  and  the  knee  will  press  against  the  opposite  thigh  some- 
what above  the  patella.  The  pain  in  the  regioi?  of  the  dislo- 
cated hip,  extending  to  the  knee  and  foot  of  the  affected  side, 
is  intense,  and  the  patient  carefully  guards  against  all  motion. 
The  causes  of  dislocation  of  the  coxo-fe moral  articulation 
are  of  a  multiple  character,  though  the  displacement  is  usually 
produced  by  a  fall,  in  which  the  force  coming  in  contact  with 
the  foot  or  knee,  carries  the  limb  in  front  of  its  fellow  and  as 
high  up  as  the  abdomen  and  perhaps  to  the  thorax,  the  femur 
being  converted  into  a  lever  of  the  first  power,  the  anterior 
edge  of  the  acetabulum  constituting  a  fulcrum,  the  head  and 
neck  of  the  bone  being  the  short  arm  of  the  lever,  which 
overcomes  the  weight  or  resistance,  which  is  the  capsnlar  and 
other  ligaments.  If  the  pelvis  be  held  firmly  in  the  cadaver 
and  the  flexed  leg  and  thigh  be  forced  into  extreme  adduction 
or  across  the  lower  part  of  the  trunk,  the  coxo-femoral  liga- 
ments will  be  heard  to*snap  ;  and  if  an  outward  force,  exerted 
parallel  to  the  femur,  be  now  imparted  to  the  limb,  to  corre- 
spond with  a  power  that  would  come  from  living  muscles,  the 
backward  dislocation  will  be  accomplished.  It  is  difficult  for 
me  to  understand  how  the  outward  dislocation  can  bo  pro- 
duced in  any  other  manner.  It  is  possible  that  the  fall  of  a 
mass  of  earth  or  other  heavy  weight,  upon  the  back  whilst 
the  body  is  bent  forward  in  a  stooping  posture,  may  produce 
the  backward  dislocation  of  the  hip,  but  it  seems  to  me  lie- 
violence  must  be  done  to  the  joint  by  the  thigh  being  doubled 
under  the  descending  trunk,  the  lower  end  of  the  femur  acting 
as  a  lever  to  pry  the  head  of  the  bone  out  of  its  socket.  In 
December,  1867,  Gus.  Bo  vine,  living  on  Freeman  St.,  fell  in 
a  tobacco  manufactory  on  Sixth  Street,  and  si  ruck  his  right 
knee  against  a  tobacco  hogshead  that  laid  upon  its  side  under 
a  hatch  through  which  the  fall  occurred.  A  couple  of  his 
fellow  workmen,  who  were  standing  near  when  the  accident 
happened,  said  they  distinctly  heard  the  breaking  sound  in  the 
joint  as  distinct  from  that  of  the  collision.  lie  this  as  it  may, 
the  outside  of  the  knee  was  hruised.  showing  the  point  hit; 
and  when  the  patient  was  raised  from  thi>  prone  '-ositiou  in 


OF  THE  FEMUR.  363 

which  he  lay,  the  dislocated  thigh  was  found  at  a  right  angle 
with  the  trunk,  and  beneath  the  lower  part  of  the  abdomen. 
When  I  saw  the  patient  first  he  had  been  taken  to  his  home ; 
and  his  leg  occupied  the  usual  position  that  it  does  in  disloca- 
tion of  the  hip  :  the  great  toe  was  resting  on  the  tarsus  of  the 
opposite  foot,  the  knee  pressed  the  thigh  of  the  well  limb,  just 
above  the  patella,  the  great  trochanter  was  rotated  forwards 
and  occupied  a  position  nearer  the  anterior  superior  spine  of 
the  iliurn  than  natural,  and  the  normal  contour  of  the  region 
of  the  hip  indicated  luxation.  By  rotating  the  limb,  while 
the  fingers  were  pressed  down  upon  the  head  of  the  bone,  its 
rotundity  could  be  discovered  and  the  motion  distinctly  felt. 
The  leg  was  stiff,  and  many  of  the  muscles  appeared  tense  and 
others  relaxed,  so  that  the  limb  felt  as  if  under  the  influence 
of  distorting  forces.  I  gave  the  patient  chloroform,  and  re- 
duced the  displacement  by  the  "physiological"  ov  manipu- 
lating plan. 

When  a  femur  is  recently  dislocated  upon  the'dorsum  of 
the  ilium,  the.shortening  is  more  apparent  than  real.  If  the 
patient  rest  straight  upon  the  back,  and  the  legs  be  arranged 
parallel  with  each  other,  and  perpendicular  with  the  trunk. 
measurements  will  show  that  the  dislocated  leg  is  not  more 
than  an  inch  shorter  than  its  fellow.  But  it  is  impracticable 
to  bring  the  limbs  parallel  with  each  other  unless  the  patient 
be  under  the  influence  of  an  anaesthetic,  and  then  the  dislo- 
cated leg  will  have  a  strong  inclination  to  flex,  and  twist  in- 
wards. If  the  dislocation  be  left  unreduced  for  several  days, 
it  will  be  found  that  the  shortening  of  the  limb  has  increased 
from  one  inch  to  two  inches. 

DIAGNOSIS  IN  THE  BACKWARD  LUXATION  OF  THE  FEMUR. — 
The  common  signs  of  dislocation  of  the  femur  backwards 
have  been  already  noticed,  but  the  fact  has"  not  been  men- 
tioned in  this  connection  that  there  is  a  slight  resemblance 
between  the  features  of  a  luxated  hip  and  those  which  belong 
to  a  fracture  of  the  neck  of  the  femur  within  the  capsular 
ligament.  In  the  shortening  of  the  limb  they  agree,  but  in 
almost  every  other  respect  they  differ.  In  fracture,  the  limb 
is  everted,  and  more  moveable  than  in  dislocation;  it  is  also 
capable  of  elongation  by  moderate  extension,  but  becomes 
shortened  on  the  remission  of  the  extending  force.  Fracture 
occurs  mostly  in  old  people,  and  from  slight  causes  ;  and  ere- 


DISLOCATIONS. 


pitus  is  a  sign  indicating  the  nature  of  the  injury  when  that 
sound  can  be  obtained,  and  it  generally  can  be  elicited  by- 
slight  rotation  of  the  limb  whilst  extension  is  being  applied. 
In  comparatively  rare  cases  the  limb  is  inverted  after  fracture, 
so  that  in  this  peculiar  feature  resemblance  to  dislocation  ex- 
ists, yet  the  remaining  characteristics  of  the  two  injuries — the 
differential  signs — are  generally  plain  and  distinctive.  Robert 
AVm.  Smith,  in  his  Treatise  on  Fractures  in  the  Vicinity  of  the 
Joints,  Case  XXIX,  reports  as  follows  :  "  Patrick  Murphy,  set. 
80,  transverse  serrated  fracture  of  the  neck  of  the  femur  ex- 
ternal to  the  capsule,  at  the  line  of  junction  of  the  cervix  with 
the  shaft  of  the  bone:  a  second  fracture  detached  the  tro- 
chanter  major,  which  was  drawn  upwards  and  backwards, 
carrying  with  it  the  insertions  of  the  pyriformis.  gemelli,  and 
obturator  muscles.  The  trochanter  minor  was  likewise  sep- 
arated from  the  shaft  of  the  femur,  and  along  with  it,  the  in- 
sertion of  the  psoas  and  iliacus  interims  ;  a  large  quantity  of 
blood  was  poured  out  between  the  fragments,  and  among  the 
muscles  around  the  joint.  The  limb  was  shortened  two  inches, 
the  foot  inverted,  and  the  entire  limb  in  a  state  of  adduction  ; 
the  trochanter  major  could  be  felt  upon  the  dorsum  of  the 
ilium,  a  little  above  the  situation  of  the  sciatic  notch.  This 
case  was  at  first  supposed  to  have  been  an  example  of  luxation 
upon  the  dorsum  of  the  ilium.  The  patient  died  upon  the 
fourteenth  day  after  the  accident."  The  case  is  reported  to 
show  that  a  comminuted  fracture  of  the  upper  extremity  of 
the  femur  may  resemble  a  dislocation  in  so  many  respects  as 
to  be  mistaken  for  that  injury,  even  by  surgeons  of  the  greatest 
experience  and  acumen.  However.  Mr.  Smith  does  not  state 
whether  the  limb  was  rigid  as  in  dislocation,  and  no  mention 
is  made  of  the  diagnostic  manoeuvre  of  extending  the  limb  to 
ascertain  if  it  could  be  easily  elongated,  audit'  so,  whether  upon 
relaxing  the  force  the  shortening  would  be  resumed.  *  These 
differential  signs,  taken  in  connection  with  the  advanced  age 
of  the  patient,  ought  to  decide  a  doubtful  case.  It  is  pre- 
sumed that  the  faulty  diagnosis  resulted  from  placing  too 
much  importance  upon  the  adduction  and  inversion.  ' 

Fracture  of  the  acetabulum  is  another  injury  which  permits 
the  limb  to  assume  many  of  the  aspects  peculiar  to  dislocation 
of  the  hip.  Several  examples  of  the  kind  are  given  by 
Cooper,  Malgaigne,  Earl,  and  others.  The  shortening  and  in- 


OF  THE  FEMUR.  365 

version  of  the  limb  which  characterized  some  of  these  cases, 
was  due  either  to  the  head  of  the  bone  being  driven  through 
the  aeetabulum  into  the  pelvis,  or  to  its  escape  from  the  ace- 
tabulum  through  the  superior  and  posterior  border  of  that 
cavity.  In  the  event  of  a  fracture  of  the  cotyloid  border,  al- 
lowing the  head  of  the  bone  to  escape,  the  reduction  would 
be  comparatively  easy,  but  there  being  no  obstacle  to  a  recur- 
rence of  the  displacement,  the  dislocation  would  be  repeated 
as  soon  as  the  extending  and  restraining  forces  were  removed. 
Arthritis,  rheumatism,  contusion,  spasm  of  the  muscles,  and 
other  injuries  and  complications  of  a  pathological  character, 
may  be  mistaken  for  dislocation,  and  be  treated  accordingly. 
It  may  be  remarked  that  some  mysterious  defects  about  the 
coy.o-femoral  articulation,  which  were  not  dislocations,  yet 
treated  as  such  by  presumptuous  "  bone-setters,"  have  been 
beiietited  by  their  senseless  manipulations. 

Dislocations  of  the  hip  have  been  overlooked,  owing  to 
some  complication  or  perplexing  circumstance.  Fergussou's 
Surgery  contains  the  following  example  :  "  A  young  woman, 
about  her  full  time  of  pregnancy,  had  a  severe  fall,  and  was 
carried  to  bed  in  a  helpless  condition ;  labor  came  on  imme- 
diately after,  and  she  had  a  difficult  time.  A  severe  rheumatic 
fever,  as  it  was  supposed,  came  on,  and  for  some  w^eeks  her 
life  was  despaired  of."  Mr.  Fergussou  was  asked  to  see  her 
when  she  was  comparatively  well,  about  three  months  after 
the  accident,  and  then,  for  the  first  time,  a  dislocation  of  the 
hip  was  detected.  The  same  surgeon  also  relates  another  case, 
where  a  dislocation  of  the  hip  was  complicated  with  a  fracture 
of  the  femur  in  its  lower  third,  and  the  dislocation  was  not 
detected  till  it  was  too  late  to  attempt  its  reduction. 

The  ischiatic  variety  of  the  backward  dislocation  is  not  a 
primary  form  of  displacement,  but  consecutive  to  the  luxation 
upon  the  dorsum  ilii.  The  same  kind  of  violence  which  pro- 
duces the  ordinary  backward  and  upward  dislocation,  may 
also  throw  the  head  of  the  bone  a  little  farther  backward  into 
the  great  ischiatic  notch,  where  the  head  o:  the  bone  rests  on 
the  pyriformis  muscle  and  against  the  sacro-sciatic  ligaments. 
The  symptoms  are  substantially  the  same  as  those  belonging 
to  the  iliac  dislocation,  though  the  shortening  is  not  so  great ; 
the  distance  between  the  great  trochanter  and  the  anterior 
superior  spinous  process  of  the  ilium  is  increased  (instead  of 


366  DISLOCATIONS. 

diminished,  as  in  the  primary  variety  of  the  backward  dislo- 
cation), and  the  head  of  the  femur  is  too  deeply  buried  in  the 
iscliiatic  region  to  be  felt,  except  in  very  spare  subjects.  In  a 
patient  who  came  under  the  observation  of  Dr.  Gross,  the 
head  of  the  femur  could  be  distinctly  felt  in  the  sciatic  notch, 
"  rolling  under  the  finger  when  the  limb  was  rotated  upon  its 
axis."  The  author  does  not  state  whether  the  patient  \vas 
emaciated  or  not,  though  it  is  presumed  from  this  circum- 
stance that  he  was.  Taking  all  the  symptoms  of  ischiatic 
dislocation  into  consideration,  it  will  be  observed  that,  this 
variety  of  displacement  causes  somewhat  less  deformity  in  the 
limb  than  the  dorsal  luxation  :  thus  the  shortening  rarely  ex 
ceeds  a  half  inch,  the  point  of  the  great  toe  rests  on  the  top 
of  the  great  toe  of  the  sound  side,  the  knee  projects  but 
slightly  beyond  the  other,  and  the  adduction,  inversion,  and 
flexion,  are  less  than  in  the  other  variety.  The  limb  is  fixed. 
and  all  voluntary  movements  are  lost.  It  is  quite  probable 
that  one  variety  of  the  luxation  is  sometimes  mistaken  for  the 
other.  Mr.  Cooper  says  that  the  ischiatic  dislocation  is 
"  most  difficult  both  to  detect  and  reduce,"  there  being  less 
deformity  and  less  fixture  of  the  limb  than  in  any  other  of 
the  displacements  of  the  thigh-bone.  "  This  obscurity  (says 
Mr.  Syme,)  is  much  increased  by  attempts  to  eft'ect  reduction, 
since  a  moderate  degree  of  extension  almost  entirely  removes 
the  shortening  and  the  inversion,  which  are  usually  considered 
the  most  characteristic  symptoms.  1  think  it,  therefore,  of 
consequence  to  state,  that  there  is  another  feature  of  the  injury 
which,  according  to  my  experience,  is  never  absent — always 
well  marked — and  not  met  with  in  any  other  injury  of  the 
hip-joint,  whether  dislocation,  fracture,  or  bruise.  This  is  an 
arched  form  of  the  lumbar  part  of  the  spine,  which  can  not 
be  straightened  so  long  as  the  thigh  is  straight,  or  in  a  line 
with  the  patient's  trunk.  When  the  limb  is  raised,  or  bent 
upward  upon  the  pelvis,  the  back  rests  flat  upon  the  bed ;  but 
as  soon  as  the  limb  is  allowed  to  descend,  the  back  becomes 
arched  as  before.  By  attention  to  this  symptom,  I  have  been 
enabled  to  recognize  the  existence  of  dislocation  into  the  ischi- 
atic notch,  when  it  had  been  unnoticed  by  others ;  and  on 
one  occasion,  when  it  was  supposed  that  the  replacement  had 
been  effected  through  powerful  extension  by  the  pulleys." 


OF  THE  FEMUR.  367 

Whether  the  ischiatic  dislocation  be  consecutive  upon  the 
dorsal  displacement  or  not,  it  is  quite  certain  that  in  attempts 
to  reduce  one  variety  of  dislocation  the  other  may  he  pro- 
duced. Many  cases  are  reported  in  which  the  efforts  at  re- 
duction baffled  the  surgeon  by  the  tendency  of  the  head  of 
the  bone  to  slip  from  the  dorsum  ilii  to  the  sciatic  notch, 
and  vice  versa;  and  even  from  the  latter  point  to  the  thyroid 
foramen.  The  CCXVII.  of  Warren's  Surgical  Cases,  is  an 
instance  of  the  kind.  The  patient  was  thirty-six  years  old  ; 
he  sustained  the  dislocation  while  attempting  to  lift  another 
man  ;  he  fell  in  making  the  effort,  and  the  weight  of  the  lifted 
man  came  against  the  thigh  and  pelvis.  For  twenty-three 
days  the  injury  was  supposed  to  be  a  sprain  ;  at  the  end  of 
that  time  the  patient  walked  a  mile  and  a  quarter  to  a  railway 
station,  and  took  the  cars  for  Boston,  where  he  came  under 
the  treatment  of  Dr.  Warren  in  the  Massachusetts  General 
Hospital.  The  limb  was  found  to  be  shortened  two  inches, 
and  more  movable  than  is  generally  the  case — a  circumstance 
which  may  have  arisen  from  the  exercise  the  limb  got  in  the 
walk  to  the  station.  The  patient  was  etherized,  and  subjected 
to  the  action  of  pulleys,  but  the  effort  failed.  Reid's  plan  was 
then  tried,  which  also  failed,  the  only  effect  being  to  carry  the 
head  of  the  bone  from  its  old  position  on  the  dorsum  of  the 
ilium,  to  a  new  one  in  the  foramen  ovale.  It  was  now  brought 
back  to  the  point  it  originally  occupied,  and  the  pulleys  were 
again  tried  ;  and  by  lifting  the  trochanter  and  rotating  the 
limb  suddenly  outwards,  the  head  of  the  bone  slipped  into  its 
normal  place  with  a  snap. 

The  New  York  Journal  of  Medicine  for  1855,  contains  the 
report  of  a  similar  shifting  state  of  the  head  of  the  femur  in 
attempts  at  reduction.  The  case  happened  in  the  New  York 
Hospital  under  the  practice  of  Dr.  Markoe.  The  patient,  seven 
weeks  previous  to  the  unfortunate  attempt  at  reduction,  re- 
ceived the  dislocation  of  the  femur  upon  the  dorsum  ilii,  by  a 
fall  from  a  rail-car  while  it  was  in  motion.  He  was  put  under 
the  influence  of  ether  and  Eeid's  method  was  tried.  "  The 
head  of  the  bone  descended  as  usual,  until  it  came  opposite 
the  lower  margin  of  the  acetabulum,  but  from  that  point,  as 
the  limb  was  brought  down,  it  slipped  on  to  the  foramen 
ovale.  The  manipulation  was  repeated  several  times,  with  all 
care,  varying  the  degree  of  abduction  at  the  various  trials. 


368  DISLOCATIONS. 

but  without  success.  It  was  impossible  to  make  the  head  rise- 
over  the  lower  border  of  the  acetabulum  so  as  to  slip  into  its 
place.  After  numerous  thorough  and  careful  trials,  the  man- 
ipulation was  abandoned  and  the  pulleys  ordered  to  be  ap- 
plied. Before  this  was  done,  it  was  thought  best  to  place  the 
head  of  the  bone  on  the  foramen  ovale,  and  from  that  point  to 
try  and  reduce  it  by  the  usual  method  recommended  by  Sir 
Astley  Cooper.  The  head  was  accordingly  placed  on  the 
foramen,  and  while  the  upper  part  of  the  thigh  was  grasped 
by  an  assistant  and  lifted  strongly  outwards,  I  took  hold  of 
the  ankle  and  made  extension  and  adduction.  The  head 
seemed  not  to  move  at  all  under  this  force,  and  while  making 
strong  adduction  a  crack  was  heard,  everything  became  loose 
about  the  joint,  and  on  examination  it  was  evident  that  a 
fracture  of  the  cervix  had  taken  place,  leaving  the  Lead  on 
the  foramen  ovale.  There  was  nothing  further  to  be-  done. 
but  to  put  the  limb  up  in  the  straight  apparatus,  hoping  that, 
if  we  could  obtain  union,  he  would  have  as  useful  a  limb  as 
those  ordinarily  left  by  fracture  of  the  cervix,  and  certainly  a 
better  limb  than  if  the  dislocation  had  been  untouched." 

TKEATMENT. — Quite  a  revolution  lias  occurred  in  recent  times 
in  regard  to  the  best  method  of  reducing  dislocations  of  the 
coxo-femoral  articulation.  Our  older  works  are  profusely  illus- 
trated with  appliances  for  exerting  great  force  in  the  reduc- 
ing process.  Pulleys  are  the  principal  means  recommended 
.for  applying  extension.  They  are  used  in  the  following  man- 
ner: the  patient  is  placed  on  his  back  upon  a  lounge,  table, 
or  bench,  in  a  locality  where  strong  hooks  or  staples,  within  a 
few  feet  of  the  patient's  position,  can  be  fixed  to  a  door-post 
or  some  immovable  object.  A  long  towel  or  stout  piece  of 
muslin,  several  yards  long,  is  carried  between  the  limbs  so  that 
its  middle  shall  rest  on  a  soft  compress  placed  against  the 
perineum,  and  its  ends,  the  one  passing  over  the  groin,  and 
the  other  over  the  buttock,  are  to  be  tied  together  and  slipped 
over  the  hook  or  staple  which  is  beyond  the  patient's  bead  ; 
the  pulleys  are  made  fast  to  the  hook  or  staple  which  is  a  few 
yards  below  the  patient's  feet,  and  reaches  to  a  wide  leather 
strap  buckled  or  laced  around  the  thigh  just  above  the  knee, 
or  to  a  towel  fastened  by  a  clove-hitch,  surrounding  the  limb 
at  the  same  point,  the  skin  being  protected  previously  with  a 


OF  THE  FEMUR.  369 

\vet  wrapping  cloth.  The  hooks  or  staples  should  he  secured 
at  points  in  the  room,  so  that  the  extending  and  counter-ex- 
tending forces  shall  he  on  a  line  with  the  axis  of  the  patient's 
body.  Everything  ready,  the  free  end  of  the  cord  in  the  mul- 
tiplying pulley  may  have  traction  gradually  made  upon  it,  till 
the  head  of  the  bone  lias  approached  the  acetahnlum.  The 
surgeon  now  uses  his  hands,  or  a  towel  around  the  upper  part 
of  the  thigh,  to  direct  the  head  of  the  bone  into  its  place. 
Sometimes  the  foot  or  knee  may  be  seized  at  the  proper  time 
during  the  extension,  and  such  rotation  imparted  to  the  limb 
as  shall  secure  reduction.  It  is  said  that  when  pulle}**  are 
used  the  head  of  the  bone  slips  into  the  acetabnlum  without 
any  audible  snap,  so  that  there  are  no  means  of  judging 
whether  the  bone  is  in  its  place,  except  by  relaxing  the  exten- 
sion, unloosening  the  apparatus,  comparing  the  length  of  the 
two  limbs,  and  ascertaining  that  the  relative  position  of  the 
trochanters  to  the  spines  ot  the  ilia  are  alike.  However,  if 
the  surgeon  have  hold  of  the  limb  while  extension  is  being 
made,  he  will,  while  aiding  the  reduction  of  the  bone,  recog- 
nize its  return  to  the  proper  place.  The  head  of  the  bone 
liavingbeen  returned  to  its  socket,  and  the  apparatus  removed, 
the  natural  contour  of  the  limb,  and  the  movements  of  the 
joint,  will  be  found  perfect!}-  restored,  which  are  reliable  tests 
of  reduction. 

In  1845,  Prof.  Gilbert,  of  Philadelphia,  published  in  the 
American  .Journal  of  Medical  Sciences,  a  method  of  multiplying 
extending  force  which  is  effective  and  more  simple  in  its  ap- 
plication than  pulleys.  It  is  a  mechanical  appliance  which 
can  be  commanded  on  almost  every  occasion,  even  in  a  rural 
district.  It  consists  in  the  utilization  of  a  "  twisted  rope." 
The  patient  is  first  arranged  as  for  the  use  of  pulleys  ;  then, 
after  the  perineal  belt  or  towel  is  secured  beyond  the  patient's 
head  to  a  hook,  staple,  or  substantial  object,  and  the  band  of 
cloth  or  leather  is  made  to  surround  the  thigh  above  the  knee, 
a  bed-cord,  clothes-line,  or  other  strong-rope,  is  doubled  and 
made  fast  to  the  extending  band,  and  again  to  a  hook  or 
staple  within  a  few  yards  of  the  patient's  knee,  in  the  axis  of 
the  limb.  A  stick  is  now  passed  between  the  doubled  or  re- 
doubled rope  at  a  point  equidistant  from  the  staple  and  the 
patient's  knee,  and  used  as  a  double  lever  to  twist  the  thongs 
or  strands,  thereby  producing  steady  but  powerful  extension. 
24 


370  DISLOCATIONS. 

The  limb  is  to  be  managed  by  the  surgeon  in  every  respect  as 
it  should  be  whilst  pulleys  are  applied. 

The  method  of  reducing  a  dislocated  femur  by  manipula- 
tion, has  been  practised  from  the  earliest  times  ;  but  no  sys- 
tematic and  well  described  and  defined  method  of  this  char- 
acter was  known  to  the  profession  until  quite  recently.  In 
the  translated  works  of  Hippocrates,  the  following  language 
is  used  in  regard  to  the  manipulating  plan  :  "In  some  the 
thigh  is  reduced  with  no  preparation,  with  slight  extension 
directed  b}7  the  hands,  and  with  slight  movement:  and  in 
some  the  reduction  is  effected  by  bending  the  limb  at  the 
joint,  and  making  rotation."  In  the  "  Chirurgical  Treatises  " 
of  Richard  Wiseman,  published  in  1676,  the  directions  for  re- 
ducing a  -dislocated  femur,  show  that  the  "  physiological '' 
principle  of  replacing  the  bone  was  pretty  clearly  understood, 
and  put  into  successful  practice.  "  If  the  thigh-bone  be  lux- 
ated inwards,  it  may  be  reduced  by  the  hand  of  the  chirur- 
geon,  viz.  :  he  must  lay  one  hand  on  the  thigh,  and  the  other 
on  the  patient's  leg,  and  having  somewhat  extended  it  toward 
the  sound  leg,  he  must  suddenly  force  the  knee  up  toward  the 
belly,  and  press  back  the  head  of  the  femur  into  its  acetabu- 
lum,  and  it  will  snap  in.  For  there  is  no  need  of  so  great  ex- 
tension in  this  kind  of  luxation  ;  for  the  most  considerable 
muscles  being  upon  the  stretch,  the  bowing  of  the  knee  afore- 
said reduceth  it."  Daniel  Turner,  who  published  his  Art  of 
Surgery  in  1742,  must  have  been  familiar  with  a  manipulating 
process  of  reducing  coxo-femoral  dislocations,  for  he  gives 
rules,  which  indicate  a  knowledge  of  such  a  method.  In  the 
Edinburgh  Medical  Commentaries  for  1776,  he  reports  a  plan 
of  reduction  which  Surgeon  Thomas  Anderson  seems  to  have 
hit  upon  when  present  at  a  case  of  dislocation,  to  reduce 
which  pulleys  were  unsuccessfully  employed.  He  says  :  "  I 
was  convinced  that  attempting  the  reduction  in  the  common 
method,  with  the  thigh  extended,  was  improper,  as  the  mus- 
cles were  all  put  on  the  stretch,  the  action  of  which  is,  per- 
haps, sufficient  to  overbalance  any  extension  we  can  apply. 
But  by  bringing  the  thigh  to  near  a  right  angle  with  the 
trunk,  by  which  the  muscles  would  be  greatly  relaxed,  I  im- 
agined that  the  reduction  might  more  readily  take  place,  and 
with  much  less  extension. 


OF  THE  FEMUR.  371 

"  When  1  made  this  examination,  he  was  lying  on  a  table 
on  his  back.  I  raised  the  thigh  to  about  a  right  angle  with 
the  trunk,  and  with  my  right  hand  at  the  ham,  laid  hold  of 
the  thigh,  and  made  what  extension  I  could.  From  this  trial 
1  found  L  could  dislodge  the  head  of  the  bone.  At  the  same 
time  that  I  did  this,  with  my  left  hand  at  the  head  and  inside 
of  the  thigh,  I  pressed  it  toward  the  acetabulum,  while  my 
right  gave  the  femur  a  little  circular  turn,  so  as  to  bring  the 
rotula  inwards  to  its  natural  situation  ;  and  on  the  second  at- 
tempt, it  went  in  with  a  snap  observable  to  the  gentlemen 
standing  around,  but  more  so  to  the  poor  man,  Avho  instantly 
cried  out  he  was  well  and  free  from  pain.  His  knees  could 
then  be  brought  together  ;  the  legs  were  of  the  same  length, 
and  the  foot  in  its  natural  situation.  The  knees  were  kept 
together  for  some  time  with  a  roller,  to  confine  the  motion  of 
the  thigh;  and  in  three  weeks  he  was  at  his  work,  without 
the  least  stiffness  in  his  joint."  Thirty  or  forty  years  later,  or 
as  early  as  1815,  Dr.  Nathan  Smith,  a  surgeon  well  known  at 
that  time  throughout  New  England,  was  in  the  habit  of  re- 
ducing dislocations  by  a  manipulating  plan,  for  in  a  case  of 
alleged  malpractice  in  which  he  was  an  expert,  he  affirmed  in 
the  following  language  :  "  I  do  not  think  that  the  mechanical 
powers,  such  as  the  wheel  and  axle,  or  the  pulleys,  are  neces- 
sary to  reduce  a  dislocated  hip,  or  any  other  dislocation." 
The  same  doctrine  he  used  to  teach  to  his  classes,  as  Professor 
of  Surgery;  and  some  of  his  pupils  have  been  known  to  carry 
his  instructions  into  successful  execution.  According  to  an 
article  published  in  the  Boston  Medical  and  Surgical  Journal 
for  May,  1840,  Dr.  Luke  Howe,  a  former  pupil  of  Dr.  Nathan 
Smith,  remembered  and  practiced  the  teachings  of  his  precep- 
tor. Dr.  Howe  says,  in  reporting  a  case:  "The  patient  was 
permitted  to  lie  on  his  back  on  the  bed  where  I  found  him, 
the  knee  of  the  luxated  limb  turned  in  and  over  the  other.  I 
raised  the  knee  in  the  direction  it  inclined  to  take,  which  was 
towards  the  breast  of  the  opposite  side,  till  the  descent  of  the 
head  of  the  bone  gave  an  inclination  of  the  knee  outwards, 
when  I  made  use  of  the  leg,  being  at  a  right  angle  with  the 
thigh,  as  a  lever  to  rotate  the  latter,  and  turn  the  head  of  it 
inwards.  It  then  readily  returned  to  its  socket,  with  an  audi- 
ble snap.  During  this  operation,  the  two  assistants  who  had 
been  placed  to  make  the  lateral  extension  and  counter-exten- 


S72  DISLOCATIONS. 

siou,  if  ultimately  required,  were  directed  to  draw  moderately 
at  their  towels.  How  much  of  the  success  of  the  operation  is 
to  be  imputed  to  their  extension,  and  the  rotation  of  the  thigh 
by  the  leg,  I  am  unable  to  determine  ;  but  as  Dr.  Smith  suc- 
ceeded without  the  aid  of  either,  and  as  the  head  of  the  femur 
seemed  to  descend  by  an  easy  and  natural  process,  I  am  in- 
clined to  believe  that  all  that  is  necessary  in  such  cases,  is  to 
elevate  the  knee,  when  the  ilium,  the  muscles  attached  to  it, 
and  perhaps  the  ligaments,  become  the  natural  fulcrum,  over 
which  the  thigh,  as  a  lever,  acts  to  bring  the  head  down  and 
inwards  into  the  socket."  In  1833,  Dr.  Wooster  Beach,  in  his 
"  Treatise  on  Surgical  Diseases,"  described  a  process  of  re- 
ducing dislocations  of  the  femur,  which  depended  upon  manual 
dexterity,  and  is  correct  in  many  particulars.  It  is  as  follows  : 
"  Instead  of  its  being  performed  by  extension  and  counter- 
extension,  it  is  done  by  a  compound  movement.  The  patient 
must  be  placed  upon  a  table,  upon  the  floor,  or  a  bed,  upon  his 
back;  then  the  practitioner  seizes  the  dislocated  leg,  and  flexes 
or  bends  it  a  little,  taking  hold  principally  of  the  knee  with 
one  hand  and  the  ankle  with  the  other.  After  having  very 
much  flexed  the  leg  upon  the  thigh,  for  the  purpose  of  c.  in- 
structing the  leg  into  a  lever,  he  carries  it  a  little  outward  ;  in 
the  next  place  the  thigh  is  to  be  gradually  abducted  ;  and 
lastly,  the  operator  freely  pushes  the  leg  upward  upon  the 
pelvis,  b}Tthe  knee,  toward  the  face,  inclining  the  knee  a  little 
to  the  opposite  side." 

In  the  August  number,  1851,  of  the  Buffalo  Me<li<-<i!  Join-tntl, 
Dr.  W.  W.  Reid,  of  Rochester,  ]ST.  Y.,  published  an  account 
of  his  method  of  reducing  dislocations  of  the  thigh,  which 
does  not  differ  essentially  from  those  already  quoted,  except 
that  the  rules  laid  down  are  definite  and  practicable.  His 
directions  are  as  follows  :  "Place  the  patient  on  his  back,  on 
a  low  firm  table,  the  floor  or  ground  is  better  ;  let  the  operator 
stand  or  kneel  on  the  injured  side,  and  seize  the  ankle  with 
one  hand,  and  the  knee  with  the  other;  then  flex  the  leg  on 
the  thigh  ;  next  strongly  adduct  it,  carrying  it  over  the  sound 
one,  and  at  the  same  time,  upward  over  the  pelvis  by  a  kind 
of  semicircular  sweep,  as  high  as  the  umbilicus;  then  abduct 
the  knee  gently;  turn  the  toes  outward,  the  heel  inward,  and 
the  foot  across  the  opposite  and  sound  limb,  making  gentle 
oscillations  of  the  thigh,  when  the  head  of  the  bone  will  slip 


OF  THE  FEMUR. 


373 


into  its  socket  with  a  slight  jerk  and  an  audible  snap,  and  the 
whole  limb  will  slide  easily  down  into  its  natural  position 
beside  the  other.  In  a  recent  case  the  whole  operation  can  be 
accomplished  in  less  time  than  it  can  be  described." 

FIG.  120. 


Manner  of  reducing  dislocations  of  the  femur  by  the  "manipulating  plan." 

Dr.  Reid  reduced  three  dislocations  upon  the  dorsum  ilii 
successfully,  and  had  no  failures  ;  and  since  the  publication  of 
his  "  plan,"  many  other  surgeons  have  followed  it,  and  gen- 
erally with  the  happiest  results.  Some  failures  are  reported 
as  having  attended  efforts  at  reduction  ;  but  it  is  possible,  if 
not  probable,  that  the  manipulation  was  not  conducted  skill- 
fully or  perseveringly.  If  the  limb  be  not  elevated  or  lifted 
well  at  the  time  the  sweep  outward  is  given,  the  head  of  the 
bone  may  slide  from  its  position,  and  not  enter  the  socket. 
In  some  instances  the  head  of  the  femur  slips  down  into  the 
thyroid  foramen ;  and  in  a  few  cases  it  has  slid  outward  into 
the  ischiatic  notch.  If  one  attempt  at  reduction  fails,  another 
should  be  undertaken;  and  even  a  bait'  dozen  or  more  trials 
maybe  made,  each  being  varied  to  some  extent.  Dr.  Bigelow 
thinks  that  the  ilio-feinoral  ligament,  which  is  an  accessory 
band  of  fibers  to  strengthen  the  capsule  on  its  anterior  aspect, 


374  DISLOCATIONS. 

plays  an  important  part  as  an  obstacle  to  reduction,  and  in 
shifting  the  head  of  the  femur  from  one  position  to  another; 
and  in  certain  cases  he  recommends  that  the  luxated  limb  be 
used  as  a  lever  to  lacerate  the  capsular  ligament  still  more,  to 
facilitate  reduction.  As  the  tense  uutorn  portion  of  the  cap- 
sule is  often  the  chief  obstacle  to  reduction,  the  suggestion 
may  be  put  into  practical  operation  in  some  instances.  It  is 
clear  that  the  manipulating  method  of  reducing  dislocations 
consists  in  placing  the  luxated  limb  in  an  attitude  Avhieh  shall 
relax  tense  tissues  whether  they  be  muscular  or  ligamentous. 
At  last,  after  repeated  failures,  the  pulleys  may  be  tried,  for 
prejudice  against  such  appliances  should  not  prevent  their 
being  used  as  a  dernier  resort.  And  even  after  the  pulleys 
have  been  tried  and  proved  inefficient,  the  manipulating  phui 
may  again  be  resorted  to  with  success.  I  should  recommend 
the  employment  of  ether  or  chloroform  in  every  instance,  un- 
less there  existed  a  contra-indieation,  or  positive  aversion,  to 
its  use. 

A  case  reported  by  Dr.  Markoe,  illustrates  what  has  just 
been  stated  :  "  The  first  opportunity  which  presented  itself 
for  the  trial  of  the  new  method,  was  in  the  case  of  an  Irish 
laborer,  who  was  brought  into  the  New  York  Hospital, 
November  30th,  1852,  with  a  luxation  of  the  right  thigh.  He 
had  been  struck,  a  short  time  before  admission,  by  the  cow 
catcher  of  a  passing  railway  train,  and  thrown  some  distance, 
and  in  his  fall,  probably,  the  accident  was  produced.  The 
symptoms  were  those  of  the  dislocation  on  the  dorsum  ilii, 
the  head  lying  rather  lower  down  and  nearer  the  ischiatic 
notch  than  usual.  The  thigh  was  shortened  about  two  inches, 
tended  across  the  other,  with  the  ball  of  the  great  toe  of  the 
injured  limb  touching  the  instep  of  the  other  foot,  fixed  in  its 
position,  and  the  head  of  the  femur  was  felt  in  the  position 
above  described  when  the  thigh  was  rotated  on  its  axis.  In 
addition  to  this  injury,  he  had  received  a  compound  fracture 
of  the  left  leg,  three  inches  above  the  ankle,  together  with  a 
good  deal  of  bruising  of  other  parts  of  his  body.  The  patient 
was  etherized  to  the  extent  of  complete  relaxation,  and  Jarvis' 
Adjuster  was  applied.  It  broke  on  the  first  trial  of  extension. 
and  was  laid  aside.  This  mischance  suggested  the  trial  of 
Dr.  Reid's  plan,  which  was  accordingly  adopted.  The  opera- 
tor, Dr.  Buck, after  bending  the  leg  upon  the  thigh,  gradually 


OF  THE  FEMIH.  375 

adducted  the  thigh,  while  at  the  same  time  it  was  being  Hexed 
upon  the  trunk.  Carrying  the  limb  thus  bent  at  the  knee, 
and  strongly  adducted  over  the  sound  thigh,  by  a  gradual 
sweep  over  the  abdomen,  and  then  slowly  and  steadily  abduct- 
ing the  limb  so  as  to  carry  the  knee  outwards,  making  at  the 
same  time  a  rocking  motion  by  moving  the  leg  backwards 
and  forwards,  had  the  effect  of  dislodging  the  head  of  the 
femur  from  its  new  position,- and  making  it  approach  the  acr- 
tabulum  ;  but  it  did  not  enter  the  socket.  From  the  position 
above  indicated,  the  limb  was  now  brought  down  slowly 
toward  a  straight  position,  still  kept  in  a  state  of  forced  ad- 
duction. This  last  manoeuvre  seemed  to  have  a  very  powerful 
influence  in  forcing  the  head  toward  the  acetabulum,  but  the 
whole  proceeding  was  completed  without  success.  It  was  ob- 
served, however,  that  the  head  had  been  moved  a  little  higher 
on  the  dorsum  than  it  was  before.  The  same  manipulation 
was  now  again  practised  more  deliberately  and  more  carefully 
than  before,  and  as  the  limb  was  being  brought  down  ab- 
ducted, we  had  the  satisfaction  of  seeing  and  hearing  the  re- 
duction effected  by  the  head  of  tne  bone  slipping  into  its 
socket.  All  deformity  had  disappeared,  and  the  motions  were 
free  in  all  directions.  The  other  injuries  were  properly 
attended  to,  and  the  recovery  from  the  effects  of  the  luxation 
was  rapid  and  satisfactory."  Dr.  Warren,  in  his  "  Surgical 
Observations,"  Case  CCXX,  reports  having  to  modify  the 
method  of  Reid  before  reduction  was  accomplished.  After 
having  made  the  knee  describe  a  segment  over  the  abdomen, 
the  head  of  the  femur  slipped  partially  around  the  socket,  but 
did  not  enter  that  cavity,  thus  altering  the  seat  of  the  disloca- 
tion, though  not  effecting  reduction.  The  ankle  wras  now 
seized  and  moderate  extension  applied,  yet  this  did  not  accom- 
plish the  object,  though  a  noise  was  heard  as  if  reduction  was 
effected.  The  leg, however,  retained  the  abnormal  shortening. 
The  limb  was  again  extended  with  considerable  force,  and  the 
trochanter  was  lifted  by  the  surgeon's  hand,  when  the  bone 
went  into  place  with  an  audible  snap.  In  this  case  the  move- 
ments given  to  the  limb  \>y  the  "physiological"  methol, 
brought  the  head  of  the  bone  to  the  border  or  rim  of  the  aco- 
tabulum,  and  simply  required  being  pushed  from  this  lodg- 
ment into  the  eavitv. 


376  DISLOCATIONS. 

Displacement  into  the  ischiatic  notch  can  be  overcome  by 
the  same  class  of  manipulations.  It  is  only  a  variety  of  the 
backward  dislocation,  consisting  mostly  in  degree  of  displace- 
ment— i.  e.,  the  head  of  the  femur  is  thrown  farther  outwards 
or  backwards  than  it  is  in  the  dorsal  luxation.  To  effect  re- 
duction the  leg  is  to  be  flexed  on  the  thigh,  the  thigh  on  the 
abdomen,  the  knee  being  made  to  rest  on  the  belly  as  high  as 
the  umbilicus  ;  and  then  takes  the  outward  sweep  till  the 
thigh  comes  to  a  right  angle  with  the  trunk,  the  surgeon  lift- 
ing upon  the  limb  so  as  to  help  the  head  of  the  femur  to  ap- 
proach the  socket,  and  to  enter  it  as  the  leg  is  allowed  to  slide 
down  into  a  position  beside  its  fellow.  If  the  manoeuvre  is 
not  a  success,  the  dislocation  will  have  been  changed  from  an 
ischiatic  into  a  dorsal  displacement.  And  the  rules  already 
given  for  the  reduction  of  that  luxation  will  then  be  appli- 
cable. According  to  the  London  Medical  Times  <n\<\  GVoV/v, 
for  August,  1856,  Mr.  "Wormald  succeeded  with  the  manipu- 
lating plan  in  a  case  that  had  been  dislocated  six  weeks,  and 
in  which  the  pulleys  had  been  repeatedly  used  in  vain. 

A  few  cases  of  serious  injury  are  reported  as  having  occurred 
from  the  manipulating  plan  of  reducing  dislocations,  though 
in  not  so  large  a  proportion  of  instances  as  in  the  method  by 
extension.  Violent  handling  of  a  dislocated  thigh  may  result 
in  fracture  of  the  neck  of  the  femur;  or,  the  head  of  the 
bone  in  changing  its  position,  as  it  sometimes  does,  may  rup- 
ture muscles  or  do  other  mischief  that  may  result  in  nbs. •<--, 
and  caries.  It  should  be  borne  in  mind  as  an  established 
principle  peculiar  to  the  plan  of  reducing  dislocations  of  the 
thigh  by  manipulation,  that  the  knee,  after  the  leg  is  flexed 
on  the  thigh,  is  to  be  carried  in  those  directions  only  which 
offer  the  least  resistance,  and  then  reduction  will  generally  be 
effected,  and  no  mischief  arise  from  the  manoeuvres.  After 
the  limb  has  taken  the  sweep  over  its  fellow,  up  toward  the 
face  of  the  patient,  it  is  to  be  abducted  more  than  to  a  right 
angle  with  the  trunk,  then  it  is  to  be  gently  oscillated  and 
lifted  with  a  strong  force,  when  the  surgeon  will  either  per- 
ceive that  reduction  is  being  accomplished,  or  that  the  effort 
ifa  a  failure,  the  head  of  the  bone  sliding  around  the  base  of 
the  socket.  If  the  surgeon  feels  that  ohe  attempt  is  a  failure, 
while  the  limb  is  yet  in  a  state  of  flexion,  he  need  not  bring 
the  foot  and  knee  down  parallel  with  the  other  limb,  but  re- 


OF  THE  FE:,IUR. 


377 


y}(.   }.> 


peat  the  manoeuvre  from  the  point  the  failure  is  perceived 
This  will  save  the  head  of  the  bone  and  the  trochanters  from 
ploughing  the  soft  tissues  so  extensively  in  different  directions. 

DISLOCATIONS  DOWNWARDS  AXD  INWARDS,  INTO  THE  OBTURA- 
TOR FORAMEN;  OR,  INWARDS  AND  UPWARDS,  UPON  THE  PUBES.— 
In  the  dislocation  downwards,  the  head  of  the  femur  is  forced 
into  the  obturator  foramen,  rupturing  in  its  descent  the  round 
and  capsular  ligaments,  and  putting  upon  the  stretch  the 
psoas  and  iliacus  muscles,  as  well  as  the 
glutei  and  the  pyriformis.  The  head  of  the 
bone  rests  uppn  the  external  obturator  mus- 
cle, and  indents  the  obturator  membrane. 
This  injury  is  produced  by  forced  abduction 
of  the  limb,  as  when  a  heavy  weight  falls 
upon  the  hips  of  an  individual  while  the 
body  is  bent;  or  by  a  fall  from  a  horse,  the 
foot  becoming  entangled  in  the  stirrup. 
Pirrie  knew  of  a  case  caused  by  a  person 
jumping  out  of  bed  in  haste;  the  right 
foot  became  entangled  by  the  blankets 
while  the  left  foot  reached  the  floor.  The 
luxation  has  also  been  known  to  occur  while 
a  person  was  entering  a  carriage,  one  foot 
being  on  the  ground,  and  the  other  on  the 
step  of  the  vehicle,  just  as  the  horses  sud- 

DislOCation  downwards  intO/1          1  efoi-f^.l  In       fVir>f  .inr     o/-.r>irlaii  +      V»TT 

the  thyroid  foramen.      Cleilly     Still  tCCl.          Ill     WCt,     any    aCClQeilt     DJ 

which  the  thighs  become  suddenly  and  vio- 
lently separated  from  each  other,  may  produce  the  dislocation 
of  one  or  both  femurs  into  the  th}Toid  foramen.  In  most  of 
the  instances  reported  the  displacement  has  been  caused  by 
the  fall  of  heavyweights  upon  the  hips,  crushing  the  individ- 
ual to  the  earth,  one  or  both  thighs  being  forced  outwards. 
The  leverage  of  the  shaft  of  the  femur,  under  such  circum- 
stances, brings  the  head  of  the  femur  to  the  lower  segment  of 
the  socket,  ruptures  the  capsular  ligament  at  that  point,  and 
forces  the  bone  through  this  rent,  down  into  the  foramen 
ovale. 

SYMPTOMS.  —  The  limb  is  held  rigid,  and  takes  a  position  in 
advance  of  the  other  ;  it  is  lengthened  to  the  extent  of  about 
two  inches  :  and  the  foot  is  not  turned  either  inward  or  out- 


378  DISLOCATIONS. 


the  trochanter  major  is  less  prominent  than  natural, 
the  body  is  bent  forwards  and  inclines  to  the  injured  side  by 
the  tension  of  the  muscles.  The  limb  can  be  abducted,  but 
can  not  be  made  to  approach  the  other  without  exciting  in- 
tense pain  and  numbness.  No  form  of  fracture  produces  these 
symptoms. 

TREATMENT.—  No  pulleys  or  kindred  appliances  are  required 
to  effect  reduction.  The  patient  is  to  be  placed  on  the  sound 
side,  and  then  the  surgeon  grasps  the  foot  and  knee  much  as 
lie  would  in  attempting  a  reduction  with  the  head  of  the  hone 
on  the  dorsum  ilii  ;  he  flexes  the  leg  on  the  thigh,  and  carries 
the  limb  into  a  position  of  extreme  abduction,  or  to  the  point 
it  was  made  to  assume  when  the  dislocation  occurred.  One 
hand  now  clasps  the  knee,  and  forces  it  into  extreme  abduc- 
tion, while  the  other  hand  placed  on  the  inside  of  the  thigh 
near  the  body,  pulls  the  head  of  the  bone  upwards  and  out- 
wards, into  the  socket.  If  the  surgeon  be  not  strong  enough 
in  his  hands  to  accomplish  this  manoeuvre  successfully,  he  can 
employ  assistants  to  help  him  execute  his  plan.  A  towel  sur- 
rounding the  thigh  near  the  trunk  and  pulled  outwards  and 
upwards  by  assistants,  while  the  surgeon  sweeps  the  knee  in- 
wards, may  prove  of  signal  service.  A  serious  objection  lo 
assistants  is,  that  they  may  direct  the  head  of  the  bone  around 
and  not  into,  the  socket,  converting  one  variety  of  dislocation 
into  another.  This  accident  has  several  times  occurred.  It 
may  not  be  amiss  to  remark,  that  should  such  an  accident 
occur,  the  head  of  the  bone  must  be  brought  back  into  its 
original  position  before  an  attempt  at  reduction  is  again  made. 
in  order  that  the  head  of  the  femur  may  be  in  the  best  place 
to  re-enter  the  socket  through  the  rent  in  the  capsular  liga- 
ment. 

In  the  case  of  Mr.  Ashfield  who  dislocated  his  left  femur 
into  the  thyroid  foramen,  by  being  thrown  from  his  horse 
while  descending  Kemper  Lane,  in  September,  1868,  I  first 
flexed  the  leg  upon  the  thigh,  then  carried  the  limb  outwards 
and  upwards,  into  extreme  abduction,  as  the  first  step  in  the 
proceeding:  I  next  placed  my  foot,  from  which  the  boot  had 
been  previously  removed  for  the  purpose,  against  the  perineum 
or  between  the  ramus  of  the  ischimn  and  the  upper  extremity 
of  the  thigh,  and  used  it  as  a  Fulcrum,  while  with  my  hands  I 
brought  the  limb  over  across  its  fellow,  when  the  head  of  the 


OF  THK  FKMFI;. 

bone1  slipped  into  place  with  an  audible  snap.  The  reduction 
was  accomplished  much  more  easily  and  cxpeditiously  than  J 
anticipated.  The  patient  was  under  chloroform,  and  resting 
upon  the  back  on  the  floor,  during  the  effort  to  replace  the  bone. 
The  picture  below  is  from  Bigelow's  illustrations,  but  the  dart 
representing  the  direction  points  in  the  wrong  way.  The  limb, 
in  a  flexed  state,  should  be  rotated  outward,  and  not  nuranl,  as 
represented.  The  rule  is  the  following:  Fle.c  the  le</  to  <i  riyht 
aiK/li  irith  tin  j't  ninr,  ami  flex  f/ie  tliiyh  enonijh  to  rela.r  (ill  tin: 
Then  ir/tli  one  liand  on  the  le<j  and  the  other  ou  the  t/iiy/>, 
iidnetion  >rit/i  rotation  ontirard  i*  to  be  imparted  to  the 
/into.  This  raises  the  head  of  the  femur  from  its  bed  in  the 
foramen  ovale,  and  the  muscles  pull  it  into  the  acetabular  socket. 
The  manoeuvre  is  easy,  and  attended  with  success.  The  rota- 
tion is  not  iu  the  direction  of  the  dart  in  the  diagram. 


:  Reduction  of  obturator  dislocation  hv  rotation  and  oircumduction 

inward .  "—Bhieloiv. 
(The  dart  points  in  the  wrong  direction.— H.) 


380  DISLOCATIONS. 

1  have  verified  what  lias  just  been  stated  in  several  trials, 
hence  I  know  what  I  am  talking  about.  In  one  instance  the 
head  of  the  femur  had  been  in  the  thyroid  foramen  for  more 
than  a  year.  The  leg  was  three  inches  too  lony,  and  much 
restricted  in  motion.  While  the  patient  was  under  chloroform 
1  rotated  the  limb  forcibly,  to  break  up  fortuitous  adhesions; 
then  I  felt  and  heard  such  bands  break.  I  then  flexed  the  leg 
to  a  right  angle  with  the  thigh;  then  with  my  right  hand  on 
the  leg,  and  my  left  on  the  thigh,  I  rotated  the  limb  outward. 
This  lifted  the  bone  from  the  thyroid  foramen,  and  the  strained 
muscles  pulled  it  upward  and  into  joint.  The  reduction  was 
attended  with  an  audible  snap.  The  limbs  became  of  equal 
length  at  once,  and  all  deformities  disappeared. 

The  cotyloid  notch  in  the  lower  border  or  Avails  of  the 
socket,  offers  an  easy  passage  way  for  the  return  of  the  bead 
of  the  femur  from  the  thyroid  foramen  to  the  acetabular 
cavity.  This  circumstance  in  the  construction  of  the  socket, 
greatly  facilitates  the  process  of  reduction.  Sometimes  the 
return  of  the  bone  to  the  socket  is  effected  by  some  slight 
movements  of  the  limb  imparted  by  anon-professional  attend- 
ant. The  powerful  muscles  put  upon  the  stretch  by  the  dis- 
placement, are  ready  to  lend  their  force  in  returning  the  bone 
as  soon  as  a  little  rocking  or  rotation  is  imparted  to  the  limb, 
to  disengage  the  head  of  the  bone  from  obstruction  in  the  way 
of  reduction. 

lu  reducing  any  variety  of  hip  dislocation,  the  inexperienced 
surgeon  can  remember  to  carry  the  limb  in  those  directions 
only  which  are  assumed  most  easily.  For  instance,  the  leg  is 
to  be  flexed  as  far  as  it  will  go  readily;  then  the  knee  is  to  be 
carried  outwards  and  upwards  in  a  state  of  abduction  until 
some  resistance  is  offered  to  the  sweep  in  those  directions,  the 
limb  reaching  nearly  to  the  thorax  in  some  cases  before  its 
course  is  arrested  ;  finally,  the  thigh,  with  the  leg  flexed  be- 
hind it,  is  to  be  moved  inwards  and  downwards,  across  the 
opposite  thigh,  completing  the  manoeuvre  which  is  to  result 
in  the  return  of  the  head  of  the  bone  to  its  natural  socket. 
If  the  thigh  be  carried  too  high,  the  knee  reaching  the  thorax, 
there  is  danger  of  throwing  the  head  of  the  femur,  not  into 
its  socket,  but  around  the  acetabulum,  into  the  ischiatic  notch. 
Experience  shows  that  the  thigh  may  be  safely  carried  to  a. 
right  angle  with  the  trunk,  and  not  endanger  the  slipping  of 


OF  THE  FEMUR.. 


381 


FIG.  l±i. 


the  Load  of  the  bone  below  the  socket  and  backward  towards 
the  ischiatic  notch.  Markoe  carried  the  knee  too  high  in  one 
instance,  and  converted  the  thyroid  into  an  ischiatic  disloca- 
tion. 

According  to  the  iSTorth-AVestern  Medical  and  Surgical 
Journal,  for  1852,  the  late  Dr.  Brainard,  of  Chicago,  reduced 
a  dislocation  of  the  femur,  which  had  been  displaced  into  the 
thyroid  foramen,  by  using  a  piece  of  wood,  well  padded,  as  a 
fulcrum,  between  the  thighs,  and  employed  the  luxated  limb 
as  a  lever  to  pry  the  head  of  the  bone  into  place.  Before  he 
tried  this  plan,  the  pulleys  and  Jarvis'  Adjuster  had  been  used 
unsuccessfully. 

I) i. ^LOCATION  UPWARDS  AND  INWARDS  UPOX  THE  PUBES. — Al- 
though this  is  called  a  dislocation  upon  the  pubes,  the  head  of 
the  femur  rests  more  upon  the  ilio-pubic  groove  outside  the 
psoas  and  iliacus  muscles,  hence  Malgaigne  has  called  it  the 
ilio-pubic  luxation,  a  term  which  better 
designates  the  position  of  the  bone,  than 
that  employed  by  Cooper  and  his  follow- 
ers. 

It  is  an  extremely  rare  form  of  disloca- 
tion, few  cases  of  the  kind  having  been 
observed,  and,  of  course,  still  fewer  dis- 
sected. It  is  a  forward  variety  of  dis- 
placement, and  does  not  occur  more  fre- 
quently than  what  is  sometimes  called  the 
perineal  dislocation,  a  form  of  luxation 
in  which  the  head  of  the  femur  is  thrown 
far  forwards  and  finds  lodgment  upon  the 
ramus  of  the  ischium. 

The  ilio-pubic  dislocation  may  be  caused 
by  a  misstep,  or  a  throwing  of  the  body 
upon  backwards  to  save  a  fall  when  the  foot  is 
placed  in  a  hole  in  the  ground,  or  upon 
an  unstable  substance.  Any  force  which  suddenly  carries  the 
thigh  outwards  and  rotates  it  at  the  same  time,  tends  to  pro- 
duce this  form  of  dislocation.  The  fall  of  a  bank  of  earth,  or 
the  wall  of  a  building,  striking  the  back  or  hips  when  the 
body  is  bent,  in  such  a  way  as  to  force  one  thigh  backwards 
twisting  it  behind  the  other,  may  also  produce  the  luxation 
under  consideration. 


Dislocation     forwards 
the  pubes. 


382  DISLOCATIONS.    * 

SYMPTOMS. — The  limb  is  everted,  abducted,  and  shortened 
to  the  extent  of  an  inch  or  more.  The  buttock  is  flattened, 
the  trochanter  is  nearer  the  anterior  superior  spine  of  the 
ilium  than  natural.  The  hemispherical  head  of  the  femur  can 
be  felt  upon  the  horizontal  ilio-pubic  bar,  outside  the  femoral 
vessels.  As  some  of  these  signs  exist  in  common  with  fracture 
of  the  neck  of  the  femur,  their  differential  peculiarities  should 
be  pointed  out.  In  fracture,  crepitus  may  be  elicited,  and 
motion  in  various  directions  may  be  easily  imparted  to  the 
limb,  the  eversion  of  the  foot  may  be  overcome  by  moderate 
force,  the  limb  can  readily  be  pulled  down  or  extended  to  its 
normal  length,  and  the  head  of  the  bone  being  in  the  socket 
can  not  be  felt,  in  dislocation,  though  there  be  shortenim-- 

'  O  o 

and  eversiou  of  the  foot,  there  is  no  crepitus,  the  limb  is  rigid, 
the  eversion  and  shortening  not  being  easily  overcome;  and 
the  head  of  the  bone  may  be  distinctly  felt  in  the  groin.  The 
thigh,  in  dislocation,  is  slightly  flexed,  and  stands  off  from  its 
fellow,  which  is  not  the  case  in  fracture  of  the  cervix  lemons. 

TKEATMENT. — Powerful  extension  may  effect  reduction,  es- 
pecially if  a  towel  be  put  around  the  thigh  near  the  body,  and 
great  force  be  used  in  pulling  the  upper  extremity  of  the  limb 
outwards  or  away  from  its  fellow.  If  this  plan  should  rail. 
the  patient  may  be  placed  on  his  sound  side,  on  the  floor  or  a 
low  bed,  and  the  leg  flexed  on  the  thigh  and  the  limb  abducted 
to  a  point  nearly  at  a  right  angle  with  the  trunk,  and  then 
adducted  much  as  in  the  manner  directed  for  reducing  dislo- 
cation into  the  thyroid  foramen.  By  this  manoeuvre  the  head 
of  the  femur  may  be  dislodged  from  its  position  on  the  ilio- 
pubic  bar,  and  returned  to  the  socket.  If  pressure  can  be 
made  on  the  head  of  the  bone,  so  as  to  help  it  towards  the 
acetabulum,  while  the  rotating  or  adducting  sweep  of  the 
knee  is  made,  the  reduction  is  more  sure  to  attend  the  effort. 

All  surgeons  who  have  reduced  dislocations  "  upon  the 
pubes  "  do  not  agree  in  their  manner  of  operating  ;  one  claims 
to  have  proceeded  nearly  in  the  course  indicated  above  ;  and 
another  manipulates  the  limb  much  as  directed  in  reducing  a 
dislocation  upon  the  dorsum  ilii.  But  how  success  could 
attend  adduction  before  the  thigh  is  first  abducted  to  bring 
the  head  of  the  bone  to  the  rim  of  the  socket,  is  more  than 
I  can  comprehend,  unless  the  dislocation  be  "  incomplete," 


OF  THE  FEMUR.  383 

the  head  of  the  hone  heing  simply  dislodged  1'rom  the  socket, 
and  resting  on  the  rim  of  the  acetabuluni.  In  this,  as  in  other 
dislocations  of  the  thigh,  the  limh  should  he  carried  in  those 
directions  offering  least  resistance,  and  then  the  operator  can 
hardly  go  astray,  even  though  he  has  made  a  faulty  diagnosis. 

ANOMALOUS  DISLOCATIONS  OF  THE  HIP-JOINT.  —  Among  the 
so-called  anomalous  dislocations  of  the  hip  may  he  mentioned 
the  upward  displacement,  the  head  of  the  bone  being  made  to 
occupy  the  notch  between  the  anterior  superior  and  the  ante- 
rior inferior  spines  of  the  ilium  ;  or  the  head  of  the  bone  may 
rest  immediately  above  the  margin  of  the  acetabuluni,  on  a 
level  with  the  anterior  inferior  spine  of  the  ilium,  and  to  its 
outside.  These  are  displacements  that  belong  to  the  backward 
variety,  if  the  head  of  the  bone  be  outside  of  the  iliac  spines; 
and  to  the  forward  variety,  if  the  head  of  the  femur  be  in  front 
of  those  processes  ;  and  must  be  treated  according  to  the  rules 
plans,  and  methods,  laid  down  for  successfully  managing  those 
forms  of  luxation. 

Downward  dislocations  vary  from  the  ordinary  forward  or 
backward  dislocations,  just  as  do  the  upward  luxations. 
Ollivier  gives  a  description  of  one  of  these  forms  of  disloca- 
tion, which  was  met  in  1819,  but  not  published  till  1823;  a 
blow  upon  the  inner  aspect  of  the  thigh  near  the  knee,  drove 
the  limb  violently  outwards,  where  it  remained  in  a  rigid  state 
of  abduction,  slightly  flexed  and  rotated  inwards;  the  head 
of  the  bone  could  not  be  felt  anywhere,  and  there  was  a  hollow 
in  the  situation  of  the  great  trochanter.  By  imitating  on  the 
dead  subject  the  mode  in  which  the  displacement  took  place, 
the  surgeon  found  that  the  head  of  the  bone  was  thrown  im- 
mediately below  the  acetabuluni,  and  behind  the  cotyloid  cav- 
ity, upon  the  tuberosity  of  the  ischium  or  into  the  lesser 
sciatic  notch.  Mr.  Keate,  in  the  Lancet,  reports  a  similar  case, 
which  was  caused  by  a  horse  falling  backwards  with  his  rider 
into  a  narrow  ditch.  The  reduction  was  accomplished  by  first 
bringing  the  head  of  the  bone  into  the  thyroid  foramen,  and 
then  into  the  socket.  It  is  probable  that  many  of  these  so 
called  anomalous  dislocations  were  primarily  either  forward  or 
backward,  varying  according  to  circumstances  in  the  upward 
or  downward  direction  ;  and  that  new  and  additional  forces 
compelled  the  head  of  the  bone  to  take  a  position  in  a  second- 
ary or  consecutive  location  quite  at  variance  with  the  ordinary 


384  DISLOCATIONS. 

displacement.  This  view  is  in  accordance  with  the  well  known 
conversion  of  a  dorsal  into  an  ischiatic  or  thyroid  luxation^ 
while  manipulating1  the  limb  in  legitimate  attempts  at  reduc- 
tion. 

AFTER-TREATMENT. — After  a  dislocated  femur  has  been  re- 
duced, a  long  splint  reaching  from  the  foot  to  the  thorax,  or 
at  least  above  the  hip,  tied  to  the  trunk  at  its  upper  extremity, 
to  the  thigh  at  its  middle,  and  to  the  foot  or  ankle  at  its  lower 
end,  should  be  worn  for  three  or  four  weeks,  or  until  it  is  pre- 
sumed that  the  rent  in  the  capsular  ligament  is  healed,  and 
other  injuries  about  the  joint  have  been  repaired.  The  splint 
keeps  the  joint  motionless,  thereby  preventing  those  move- 
ments that  favor  re-dislocation.  Locally  applied  sedatives 
may  restrain  high  grades  of  inflammation  that  might  result 
in  abscess  and  other  serious  complications. 

ANCIENT  DISLOCATIONS  OF  THE  COXO-FKMOKAL  AKTKTLATION. 
— There  is  no  set  time  at  which  -A  ['eduction  of  a  dislocated 
hip  may  not  be  attempted,  though  there  is  not  much  hope  of 
success  after  three  or  four  months  have  elapsed  from  the  re- 
ception of  the  accident.  Malgaigne  reports  having  known  a 
dislocated  hip  to  be  successfully  reduced  after  the  head  of  the 
femur  had  been  displaced  for  a  whole  year.  In  March,  1856, 
Dr.  Blackmail,  at  the  Commercial  Hospital,  in  this  city,  re- 
duced a  dislocation  of  the  hip  that  was  of  six  months'  stand- 
ing. The  reduction  was  accomplished  by  the  manipulating 
plan.  Dr.  Dupierris,  a  Cuban  surgeon  of  distinction,  also  re- 
duced a  dislocation  of  the  femur,  which  had  been  received 
more  than  six  months  previously.  The  operation  was  per- 
formed by  manual  dexterity,  and  not  by  the  aid  of  pulleys  or 
other  appliances  for  multiplying  force. 

Such  results  at  late  periods  after  the  accidents  occurred, 
warrant  the  attempt  at  reduction,  even  if  several  months  have 
elapsed  from  the  time  the  luxation  is  received.  Though 
the  acetabular  cavity  be  partially  filled  during  the  long  absence 
of  the  head  of  the  femur,  the  return  of  that  bone  will  soon 
re-establish  all  the  functions  of  the  joint. 

It  would  not  be  wise  to  consider  these  successful  efforts  at 
reduction,  in  ancient  dislocations,  as  establishing  a  rule,  for  in 
all  probability  many  unsuccessful  attempts,  even  in  cases  of 
not  more  than  two  or  three  months'  standing,  have  been  made  ; 
and  because  they  proved  to  be  failures,  they  passed  uureported. 


OF  THE  FEMUR.  385 

It  would  be  safer,  then,  to  consider  these  successes  in  the  re- 
duction of  dislocations  of  six  months'  standing,  as  exceptions, 
and  the  unreported  failures  as  constituting  the  rule. 

C<IM;I:.\ITAL  DISLOCATIONS  OF  THE  HIP. — These  constitute  a 
class  of  difficulties  that,  as  a  general  rule,  can  not  be  remedied 
by  the  ordinary  methods  of  reducing  luxations,  therefore  they 
are  not  strictly  admissible  in  this  connection.  In  the  majority 
of  such  instances  there  is  some  osseous  defect  about  the  articu- 
lation, to  say  nothing  of  lax  ligaments  and  muscles.  Occur- 
ring mostly  in  children  of  a  scrofulous  and  flaccid  condition, 
or  those  having  a  soft  and  yielding  state  of  the  bones,  the 
acetabular  walls  become  elongated  upward,  or  the  head  of  the 
femur  absorbed  to  an  extent  that  displacement  is  a  necessity, 
and  can  not  be  fully  remedied. 

PARTIAL  DISLOCATIONS  OF  THE  FEMUR.  —  Occasionally  cases 
will  be  met,  especially  in  the  young,  where  there  is  some 
strange  defect  of  the  coxo-femoral  articulation  which  resem- 
bles a  dislocation  in  many  respects,  yet  no  positive  evidence 
exists  that  the  head  of  the  femur  completely  leaves  its 
socket.  In  some  instances  it  seems  probable  that  the  head  of 
the  bone  rests  on  the  edge  of  the  acetabular  cavity,  being  pre- 
vented from  descending  on  the  slope  outside  the  cavity  by  the 
untorn  state  of  the  capsular  ligament,  yet  it  does  not  seem 
possible  that  in  anything  like  a  normal  state  of  the  fibrous 
tissues  the  capsular  ligament  will  stretch  sufficiently  to  allow 
the  head  of  the  femur  to  rise  out  of  its  deep  socket  and  take 
a  position  on  the  border  of  the  cavity  and  there  rest  poised 
until  absorption,  under  pressure,  has  formed  an  imperfect  cup 
for  the  point  of  the  bone  to  move  in,  and  not  be  liable  to 
escape,  either  inside  or  outside  the  true  articular  cavity. 
However,  surgeons  of  unquestioned  ability  have  reported  in- 
complete luxations  of  the  femur,  giving  the  lesion  a  legitimate 
place  am^ng  hip-joint  dislocations.  It  is  probable  that  some 
mistake  has  arisen  in  regard  to  the  nature  and  extent  of  the 
injury,  yet  when  a  limb  bears  several  of  the  prominent  signs 
of  dislocation,  and  no  other  lesion  is  suspected,  it  would  natu- 
rally be  pronounced  luxated.  There  are  some  mysterious  de- 
fects more  or  less  peculiar  to  the  coxo-femoral  articulation, 
that  may  require  a  long  course  of  inquiry  and  investigation 
to  clear  up.  About  a  year  ago  I  was  called  to  see  a  little  girl 
who  had  been  hurt  in  the  street,  and  was  unable  to  walk 
25 


386  DISLOCATIONS. 

home ;  she  had  complained  of  something  breaking  or  giving 
way  in  her  hip,  and  her  physician  went  through  with  a  variety 
of  manipulations,  and  claimed  to  have  reduced  a  dislocatiou. 
At  the  time  I  was  called,  two  weeks  after  the  reception  of  the 
injury,  the  trochanter  was  very  prominent,  the  leg  was  rigid, 
inverted,  and  to  all  appearance  an  inch  or  two  shorter  than 
the  other. 

The  parents  remarked  that  if  the  limb  was  ever  dislocated 
the  bone  was  still  out  of  place,  for  it  had  presented  the  same 
appearance  ever  since  the  accident,  notwithstanding  the 
doctor's  claims  to  having  effected  reduction.  Movements  im- 
parted to  the  limb  gave  great  pain ;  there  was  no  crepitation, 
or  other  marked  sign  of  fracture  ;  the  head  of  the  femur  was 
not  outside  the  socket,  though  it  seemed  lifted  part  way  out, 
and  could  not  be  made  to  return.  I  interpreted  the  symptoms 
as  indicating  inflammation  of  the  joint,  the  head  of  the  bone 
being  raised  in  the  socket  by  swelling,  effusions,  or  morbid 
products  in  the  bottom  of  the  socket.  The  girl  now  walks 
about,  with  the  foot  inverted,  the  limb  apparently  shortened, 
though  a  twist  in  the  pelvis  prevents  that  feature  from  being 
observable ;  she  is  a  little  lame,  but  is  improving  in  her  gait 
and  general  appearance.  I  think  there  never  was  in  her  case, 
any  form  of  traumatic  dislocation,  but  that  she  labored  under 
a  species  of  hip-disease. 

DISLOCATION  OF  THE  HIP  COMPLICATED  WITH  FRACTURE  OF 
THE  FEMUR. — Under  extraordinary  circumstances  the  head  of 
the  femur  may  be  dislocated,  and  then,  in  the  same  accident, 
the  neck  of  the  bone  or  upper  extremity  of  the  shaft,  may  be 
broken.  The  London  and  Edinburgh  Monthly  Journal  of 
Medical  Science,  for  December,  1843,  contains  an  account  of 
such  an  injury,  which  was  verified  by  a  dissection  made  after 
the  patient's  death,  which  occurred  twelve  years  after  the  re- 
ception of  the  injury.  The  dislocation  was  of  the  pubic 
variety,  and  the  head  of  the  femur  was  completely  olisengaged 
from  the  neck  and  shaft  of  the  bone.  It  is  not  stated  in  the 
report  whether  any  attempt  had  been  made  to  reduce  the  dis- 
location, during  which  the  neck  of  the  femur  may  have  been 
accidentally  broken.  It  is  not  improbable  that  in  some  in- 
stances the  femur  is  broken  in  attempts  at  reduction ;  and  the 
complication  may  not  have  been  recognized  or  acknowledged. 
In  the  event  of  dislocation  and  fracture  of  the  femur  in  the 


OF  THE  FEMUR.  387 

same  accident,  a  judicious  attempt  should  be  made  to  push 
the  head  of  the  bone  into  the  socket,  before  the  fracture  is 
treated.  If  the  effort  fail,  the  question  would  arise  whether 
it  is  best  to  seek  a  union  of  the  fragments,  or,  if  the  fracture 
was  through  the  neck  of  the  bone,  to  preserve  the  limb  in  as 
natural  a  position  as  possible,  and  expect  only  such  a  state  of 
the  parts  as  exists  in  a  case  of  non-union  after  fracture  of  the 
cervix  femoris.  If  the  fracture  was  through  the  shaft  of  the 
bone  at  some  distance  from  the  cervix,  and  the  reduction  of 
the  dislocation  could  not  be  accomplished,  a  good  union  of  the 
fragments  should  be  secured,  and  then  an  attempt  might  be 
made  to  replace  the  head  of  the  bone,  as  in  an  ordinary  case 
of  ancient  or  chronic  dislocation.  The  attempt  at  reduction 
should  not  be  made  until  the  fracture  has  been  treated  eight, 
ten,  or  twelve  weeks,  the  ;ige  and  vigor  of  the  patient  influ- 
encing the  time  consumed  in  the  treatment. 

In  connection  with  the  diagnosis  of  dislocated  femurs,  it 
must  be  borne  in  mind  that  in  luxation  upon  the  dorsum  ilii, 
the  back  arches  prominently  upwards  as  the  patient  rests  up- 
on a  table  or  level  surface  ;  and  the  muscles  of  the  thigh  are 
baggy  underneath,  and  tense  or  drawn  down  to  the  bone  on 
top,  or  on  the  front  aspect  of  the  femur.  In  a  dislocation 
into  the  thyroid  foramen  the  muscles  and  tendons  on  the  in- 
side of  the  thigh  near  the  groin  are  tort.  It  is  to  be  remem- 
bered also  that  a  consecutive  dislocation  upon  the  dorsum  ilii, 
the  luxation  being  first  into  the  foramen  ovale,  must  be  re- 
duced by  carrying  the  head  of  the  femur  back  to  the  thyroid 
foramen,  then  into  place.  "When  the  head  of  the  femur  has 
passed  from  the  foramen  ovale  to  the  dorsum  ilii,  it  can  not 
go  directly  into  the  socket,  for  no  aperture  exists  through 
which  it  can  pass,  but  it  must  retrace  its  steps — it  must  go 
back  by  the  route  taken  in  the  beginning. 

In  reducing  dislocation  of  the  hip,  the  patient  is  handled 
best  on  the  floor,  with  a  quilt  for  a  bed.  If  one  kind  of  man- 
ipulations do  not  succeed,  the  surgeon  is  to  take  a  rest,  and 
reconsider  all  the  conditions  of  the  case.  He  is  to  question 
himself  whether  or  not  a  consecutive  dislocation  has  not  in- 
tervened since  the  first  occurred.  The  surgeon  commencing 
the  introductory  manipulation  may  convert  a  grimary  into  a 
secondary  or  consecutive  luxation. 


CHAPTER  XII. 


DISLOCATION    OF    THE    PATELLA 


The  patella  may  be  dislocated  laterally,  i.  e.,  outwards  or  in- 
wards; and  the  bone  has  been  forced  upon  its  edge.  It  can 
not  be  dislocated  downwards  ;  nor  upwards  without  a  rupture 
of  the  ligamentura  patellae.  The  outward  displacement  is  not 
an  uncommon  accident,  but  the  other  forms  are  quite  rare. 
Muscular  action  is  the  most  common  cause  of  the  displace- 
ment, though  direct  violence,  as  a  blow  upon  the  knee  received 
Fia.  123.  *n  a  ^a^>  has  been  known  to  force  the  bone 
from  its  natural  position.  Young  women  of 
lax  ligaments,  whose  wide  hips,  and  approxi- 
mating knees,  throw  the  patella  inside  of  a 
line  drawn  from  the  tubercle  of  the  tibia. 
where  the  ligamentum  patella?  is  inserted,  to 
the  centre  of  the  origin  and  action  of  the  qua- 
driceps muscle,  are  most  liable  to  this  accident. 
It  is  obvious  that  the  muscles  which,  in  going 
to  their  insertion,  are  made  to  swerve  inwards 
to  embrace  the  patella,  would  in  their  con- 
tractions tend  to  displace  that  bone  outwards. 
There  are  several  varieties  of  the  outward  dis- 
placement ;  the  bone  may  be  partially  luxated 
or  thrown  so  far  outwards  that  the  inner  artic- 
ular half  of  the  patella  would  rest  upon  the 
outer  condyle ;  and  owing  to  the  obliquity  of 
the  surfaces  in  contact,  the  outer  edge  of  the 
bone  is  made  to  project  prominently.  In  a 
complete  dislocation,  the  patella  is  thrown 
wholly  outside  the  most  prominent  point  of  the  external  con- 
dyle,  and  the  inner  edge  of  the  displaced  bone  is  made  to 
project  forward.  The  capsule  of  the  joint  is  more  or  less 

(388) 


389 

lacerated  by  the  complete  luxation.  The  inward  dislocation, 
which  i.s  a  rarer  form  of  injury,  is  generally  produced  by  direct 
violence,  and  not  by  muscular  action.  Blows  received  in  falls, 
are  the  common  cause. 

In  the  dislocation  edgeways  the  patella  is  turned  on  its  axis, 
so  that  the  articular  surfaces  of  the  patella  face  inwards,  and 
the  front  surface  outwards,  the  outer  edge  of  the  bone  being- 
buried  in  the  fossa  between  the  coudyles. 

There  is  no  difficulty  in  detecting  the  nature  of  these  dis- 
placements ;  the  patella  can  be  easily  felt  in  its  unnatural  posi- 
tion, the  bone  being  forced  upon  its  edge  or  too  far  inwards, 
or  outwards.  The  knee  after  luxation  of  the  patella  is  par- 
tially flexed  and  too  firmly  fixed  to  admit  of  voluntary  motion. 
Any  attempt  to  move  the  limb  is  attended  with  great  pain. 
In  the  lateral  dislocation  the  width  of  the  knee  is  increased ; 
and  the  position  usually  occupied  by  the  patella  presents  a 
depression  to  be  both  seen  and  felt.  In  April,  1860,  1  was 
called  to  see  a  boy  on  Fifth  Street,  opposite  the  Market  House, 
who  in  falling  down  stairs  hit  his -left  knee  against  the  corner 
of  a  box,  and  received  a  dislocation  of  the  patella  inwards. 
The  mother  who  was  near  when  the  accident  occurred,  carried 
the  boy  up  stairs,  and  tried  to  make  him  stand  and  walk ;  but 
he  complained  that  his  knee  was  broken,  and  he  could  not  use 
it.  I  found  the  leg  considerably  flexed,  rigid,  and  excessively 
painful.  After  taking  off  the  patient's  pants,  I  recognized  the 
nature  of  the  injury  at  once  ;  and  proceeded  without  delay  to 
replace  the  bone.  1  encountered  more  resistance  to  a  return 
of  the  bone  than  I  had  anticipated.  At  first  I  attempted  to 
extend  the  limb  to  relax  the  quadriceps,  but  could  not  do  it 
without  eliciting  the  sharpest  cries  from  the  patient.  I  found 
the  patella  would  not  readily  slip  over  the  high  edge  of  the 
inner  condyle,  so  I  sent  for  chloroform,  and  when  the  patient 
was  well  under  its  influence,  I  had  no  trouble  in  pulling  the 
patella  outwards  into  its  place,  the  fingers  being  strong  enough 
to  lift  it  to  a  point  where  the  action  of  the  muscles  would  re- 
place the  bone. 

TREATMENT.  -The  outward  displacement  may  generally 
be  oven-ome  by  slight  movements  of  the  joint,  and  firm 
pressure  made  against  the  outside  of  the  bone  ;  but  the  displace- 
ment inwards,  and  the  edgeways  dislocation,  are  more  diffi- 
cult to  replace  or  return  to  position.  In  these  forms  of  dis- 


390  DISLOCATIONS. 

placement  great  force  is  required  to  effect  reduction,  and  alt 
movements  are  attended  with  extreme  pain,  therefore  the 
quieting  and  relaxing  effects  of  an  anaesthetic  should  be 
brought  into  requisition.  A  case  is  reported  by  Dr.  Gazzom, 
of  Pittsburg,  Pa.,  in  which  a  man  in  a  wrestling  match  was 
thrown,  and  was  unable  to  rise  on  account  of  the  patella  hav- 
ing been  dislocated  upon  its  axis,  the  edge  of  the  bone  resting 
in  the  sulcus  between  the  condyles.  Varied  and  repeated  at- 
tempts at  reduction  failed;  the  doctor,  by  the  advice  of  an- 
other physician,  divided  snbcutaneously  the  ligamentum 
patellae  close  to  the  tubercle  of  the  tibia,  and  then  made  efforts 
at  reduction  but  failed  ;  bleeding  to  syncope  was  tried,  yet  the 
bone  could  not  be  adjusted;  the  next  day  the  leg  was  flexed 
on  the  thigh,  and  the  thigh  on  the  pelvis,  and  then  the  leg 
suddenly  straightened,  according  to  the  suggestion  <>f  Dr. 
Watson,  who  placed  his  patient  in  a  chair,  and  then  taking 
his  foot  upon  the  shoulder,  flexed  the  knee  a  little  by  the  for- 
ward inclination  of  the  body,  and  then  suddenly  extended  the 
leg,  the  hands  being  used  to  help  execute  the  manoauvre.  This 
plan  succeeded  with  Dr.  Gazzom  upon  a  fourth  trial. 

Mr.  Flower  had  a  case  in  a  lad  who  fell  between  the  seats 
of  a  theatre  gallerv,  the  patella  beinsr  forced  half  wav  round 

o  *>   *  i.  i_*  %> 

and  turned  up  edgeways,  between  the  condyles  of  the  femur 
and  the  head  of  the  tibia.  The.  limb  was  extended,  and  all 
attempts  at  reduction  by  bending  the  knee,  manipulating  the 
patella,  etc.,  were  unavailing.  Chloroform  was  then  admin- 
istered, and  the  bone  easily  replaced. 

If  the  ligameutum  patellae  be  ruptured  or  extremely  relaxed, 
the  patella  maybe  displaced  upwards.  This  could  not  be 
legitimately  considered  a  dislocation,  but  a  rupture  of  the  ten- 
don. Such  an  injury  should  be  treated  in  even  respeet  as  if 
it  were  a  fracture  of  the  patella. 

It  is  often  difficult  to  keep  a  patella,  which  has  once  been 
dislocated,  in  place;  therefore  when  the  bone  is  once  reduced, 
an  elastic  knee-cap  should  be  worn,  or  an  apparatus  with  a 
ring  or  disc  on  the  side  the  dislocation  has  occurred  Side 
irons  extending  a  few  inches  above  and  below  the  knee,  jointed 
in  the  middle,  and  having  a  semi-circular  iron  hand  at  each 
end  to  surround  the  posterior  half  of  the  leg  and  thigh,  and 
straps  to  buckle  over  the  front  part,  may  be  worn  to  strengthen 
the  joint  and  to  prevent  re-luxation. 


CHAPTER    XIII. 


DISLOCATION  OF  THE  TIBIA 


FIG.  124. 


The  tibia  may  be  dislocated  forwards,  backwards,  and  to 
either  side,  though  it  is  seldom  displaced  in  any  direction. 
The  articular  surfaces  at  the  knee-joint  being-  large,  and  the 
connecting  ligaments  exceedingly  strong,  luxation  can  not  be 
produced  without  great  displacing  power  be  brought  to  bear. 
The  lateral  dislocations  are  frequently  partial,  but  the  for- 
ward and  backward  luxations  are  generally  complete,  the  tibia 
being  also  rotated  in  some  degree  upon  its  axis. 

In  the  backward  dislocation  the  head  of 
the  tibia  forms  a  projection  in  the  ham, 
and  a  deep  depression  exists  in  front  of 
the  knee,  below  the  protuberant  condyles 
of  the  torn  in-.  The  lower  end  of  the 
patella  follows  the  tibia,  and  thus  becomes 
placed  horizontally,  with  its  anterior  sur- 
face looking  downwards  and  its  upper 
margin  forwards.  The  limb  may  be 
straight  or  forcibly  extended.  The  mus- 
cles about  the  knee  are  nearly  all  put 
upon  the  stretch,  and  the  vessels  and 
nerves  of  the  popliteal  space  are  coin- 
pressed.  If  the  tibia  be  thrown  entirely 
behind  the  articular  surfaces  of  the  con- 
dyles, the  crucial  ligaments  will  be  torn, 
and  other  tissues  about  the  joint  stretched 
or  lacerated. 

The   backward   luxation    is    generally 

produced  by  direct  violence  applied  to   the  upper  and   front 
part  of  the  tibia  when  the  knee  is  bent. 


Dislocation    of    the    tibia 
backwards, 


392  DISLOCATIONS. 

TREATMENT. — When  the  patient  is  under  chloroform  there 
is  no  great  difficulty  in  reducing  the  hone  by  manipulation. 
If  ordinary  manipulation  fail,  an  assistant  may  hold  the  thigh 
upon  the  arm  of  a  sofa,  foot-board  of  a  bed,  or  any  projecting 
ridge,  while  the  surgeon  extends  the  leg  if  it  be  flexed,  or, 
flexes  it  if  in  a  state  of  extension,  at  the  same  time  pulling 
the  leg  into  position.  It  is  rarely  necessary  to  make  use  of 
pulleys  or  other  appliances  for  exerting  powerful  extending 
and  counter-extending  forces.  The  hands  of  another  assistant 
to  push  the  tibia  forward  and  the  femur  backward,  might  aid 
iu  the  work  of  reduction. 

Dr.  Rose,  in  the  Provincial  Medical  Journal,  reports  being 
present  when  a  woman  had  the  tibia  dislocated  backwards  by 
a  fall  occasioned  by  a  carriage  being  driven  furiously  against 
a  ladder  on  which  she  was  standing.  The  knee  was  rigidly 
held  in  a  state  of  fixed  extension.  The  patient  being  relaxed 
from  the  shock  of  the  injury,  the  doctor  had  no  difficulty  in 
pressing  the  displaced  bones  into  position  ;  and>ln  the  course 
of  a  few  weeks,  under  the  influence  of  local  antiphlogistic 
treatment,  the  woman  made  a  successful  recovery. 

The  forward  dislocation  of  the  tibia  is  a  rare  accident,  and 
presents  features  quite  the  reverse  of  the  backward  displace- 
ment :  the  tibia  and  patella  project  forwards,  and  the  condyles 
of  the  femur  produce  a  swelling  in  the  ham.  The  popliteal 
artery  and  nerves  are  compressed  to  the  extent  of  endangering 
gangrene;  the  ligaments  about  the  joint  are  lacerated  ;  and 
the  limb  is  more  or  less  shortened  and  extended.  The  pro- 
jection of  the  leg  bones  in  front  and  the  femur  behind,  clearly 
indicate  the  nature  of  the  displacement. 

The  causes  of  this  injury  in  cases  reported,  have  been  the 
stepping  into  a  ditch  while  carrying  a  heavy  weight ;  the  fall- 
ing of  a  heavy  spar  on  a  man's  back,  the  knee  being  forced 
to  give  way  under  the  weight  and  shock;  and  direct  blows. 
Malgaigne  is  of  the  opinion  that  neither  the  forward  nor  the 
backward  dislocation  of  the  tibio-femoral  articulation  is  com- 
plete, though  it  would  be  difficult  to  account  for  the  shortening 
in  the  cases  reported,  if  the  luxations  were  only  partial. 

October  10th,  1860,  I  was  called  by  Dr.  Adams,  of  Covington, 
Ky.,  to  see  a  negro  boy  who  received  an  injury  of  the  knee; 
by  falling  into  a  coal  barge  anchored  in  the  Licking  river. 
The  boy  in  falling  backwards  struck  the  edge  of  a  projecting 


OF  THE  TIBIA.  393 

board,  which  hit  just  above  the  calf  of  his  right  leg  The 
upper  part  of  the  leg  was  driven  forwards,  and  the  condyle.-? 
of  the  femur  were  prominent  in  the  popliteal  space.  The  for- 
ward dislocation  of  the  tibia  was  unmistakable;  and  its  re- 
duction was  effected  by  manipulation,  while  the  lower  part  of 
The  thigh  projected  over  a  chair.  The  leg  was  found  in  a 
forcibly  extended  position.  The  boy  received  other  injuries 
of  a  serious  nature,  but  ultimately  recovered  perfectly  from 
all.  His  left  ulna  was  broken  by  direct  violence  through  its 
upper  third,  and  it  was  thought  that  the  eighth  rib  was 
broken  near  its  angle. 

Dr.  Sanborn,  of  Lowell,  Mass.,  reports  through  the  Boston 
Medical  and  Surgical  Journal,  for  1856,  a  case  of  dislocation 
of  the  tibia  forwards  which  was  produced  by  moving  machin- 
ery in  one  of  the  factories  of  the  city,  the  man  being  caught 
in  a  belt  and  carried  round  a  shaft,  the  leg  hitting  the  timber 
above  at  each  revolution.  At  first  sight  the  lirnb  seemed  to 
be  broken  in  many  places  ;  it  was  shortened  by  several  inches 
and  shapeless  ;  a  closer  examination  proved  that  no  fracture 
existed,  but  a  complete  dislocation  of  the  tibia  forwards,  the 
condyles  of  the  femur  being  driven  down  beneath  the  gastroc- 
nemius  muscle;  and  the  tibia  rose  up  in  front,  forming  a 
marked  projection.  An  assistant  held  the  pelvis,  and  the  sur- 
geon grasped  the  ankle  and  drew  the  leg  downwards  to  its 
proper  length  ;  and  the  bones  then  slipped  into  place.  The 
patient  made  a  satisfactory  recovery. 

The  treatment  of  the  forward  dislocation  is  to  be  managed 
on  precisely  the  same  principles  as  the  backward  luxation  ; 
the  patient  is  to  be  put  under  the  relaxing  and  stupefying 
effects  of  chloroform,  and  then  the  surgeon  extends  the  leg 
.and  pushes  the  displaced  bones  into  their  natural  relations. 
If  he  is  unable  to  accomplish  reduction  alone,  he  can  engage 
the  strength  of  assistants  to  good  advantage.  In  those  cases 
of  forward  and  backward  dislocations  which  obstinately  oppose 
reduction,  it  is  not  improbable  that  the  lateral  ligaments, 
when  they  escape  untorn,  offer  the  chief  resistance.  To  over- 
•come  these  obstacles  the  leg  would  have  to  be  forcibly  flexed 
or  extended  to  relax  the  tense  tissues.  If  the  leg  was  found 
in  a  partially  flexed  condition,  it  would  have  to  be  flexed  still 
more;  if  in  a  state  of  extension,  it  should  be  extended  even 


394 


DISLOCATIONS. 


beyond  the  straight  attitude,  before  the  displaced  bone  would 
slide  into  place. 

The  outward  and  inward  dislocations  of  the  head  of  the  tibia, 
as  lias  already  been  stated,  are,  on  account  o'f  the  width  of  the 
knee-joint,  only  partial.  A  violent  twist  of  the  leg,  coupled 
with  the  displacing  force  the  leg  often  sustains  in  a  fall  of  the 
body,  and  the  effects  of  moving  machinery,  are  accounted  as 
the  common  causes  of  lateral  dislocations  of  the  tibia.  The 
signs  of  the  displacement  are  too  strongly  marked  to  pas 


FIG.  125. 


undetected.  There  is  no  shortening. 
but  the  limb  is  rigid,  slightly  flexed. 
with  the  foot  inverted  or  everted  as 
circumstances  may  direct.  The  prom- 
inent projections  laterally  of  the  fern  in- 
to one  side,  and  the  tibia  and  fibula  to 
the  other,  exhibit  the  ti»ue  state  of  tin- 
injury.  The  width  of  the  joint  is 
greatly  increased,  and  the  limb  will 
almost  always  present  a  twisted  appear- 
ance, there  being  some  rotation  of  the 
tibia  upon  its  axis.  The  accident  can 
not  occur  without  considerable  lacera- 
tion of  ligaments,  and  straining  of 
muscles. 

TREATMENT.  —  Lateral  dislocations  of 
the  knee  are  reduced  with  greater  facil- 
ity than  any  other  luxation  of  impor- 
tance iu  the  body.  An  assistant  holds 
Lateral  dislocation  of  the  tihhi.  £]ie  thigh  fixed,  and  the  surgeon  make- 
extension  and  pushes  the  head  of  the  tibia  in  the  direction 
favoring  a  return  of  the  bones  to  their  natural  positions. 
After  reduction  is  accomplished,  the  joint  must  be  kept  per- 
fectly motionless  for  two  or  three  weeks,  and  the  ordinary 
remedies  employed  for  preventing  or  subduing  inflammation. 
Passive  motion,  which  would  be  serviceable  in  preventing  an- 
chylosis, might  also  interfere,  with  the  healing  of  the  lacerated 
ligaments;  therefore  it  should  be  employed  with  due  regard 
to  the  state  of  all  the  parts  implicated. 

DISPLACEMENTS  OP  THE  SEMI  LUNAR  C\I;TI  LACKS.  —  Chronic  in- 
flammation of  the  knee-joint,  caused  by  ;:  strain,  or  other  in- 
jury, is  sometimes  followed  by  thickening  of  the  semilunar 


OF  THE  TIBIA.  395 

cartilages,  and  by  elongation  of  the  ligaments  which  connect 
them  with  the  tibia ;  and  it  may  create  other  difficulties  with 
the  internal  working  of  the  joint,  so  that  the  cartilages  may 
become  displaced  by  some  trivial  effort  in  the  use  of  the  foot. 
For  the  time  the  patient  falls,  or  is  unable  to  walk  until  the 
limb  is  gently  flexed  and  twisted,  when  the  defect  is  overcome, 
and  the  leg  resumes  all  its  functions  without  evidence  of 
serious  impairment.  This  injury  has  passed  among  surgical 
writers  and  teachers  as  a  sub-luxation  of  the  semilunar  carti- 
lages, though  little  is  positively  known  in  regard  to  the  path- 
ology of  the  difficulty.  It  is  possible  that  the  cartilages  do 
become  slightly  displaced,  so  that  some  part  of  their  structure 
gets  pinched  between  the  condyles  of  the  femur  and  the  head 
of  the  tibia.  Surgeons  have  declared  that  they  have  found 
the  cartilages  projecting  outwards  at  some  part  of  the  articu- 
lation. In  a  few  instances  what  was  supposed  to  be  a  displace- 
ment of  the  semiluuar  cartilages,  has  turned  out  to  be  loose  or 
false  cartilages  in  the  joint.  M.  Gimelle  has  related  a  case  of 
this  kind,  the  mistake  being  corrected  by  Larrey  who  cut  into 
the  joint  and  removed  the  foreign  body. 

In  some  patients,  either  from  lax  ligaments,  or  a  predispo- 
sition to  joint  affections,  the  knee  is  constantly  tender  and  un- 
stable. A  slight  twist  imparted  to  the  joint  in  walking,  or 
even  while  turning  in  bed,  is  followed  by  sickening  pain,  and 
acute  arthritis.  The  difficulty  may  be  regarded  in  most  in- 
stances as  a  morbid  sensibility  of  the  joint  structures  which 
will  pass  off  in  the  course  of  time,  even  if  nothing  be  done  ; 
but  it  would  be  judicious  to  put  such  patients  on  tonic  and  re- 
storative treatment  to  remove  any  constitutional  dyscrasia,  and 
to  bathe,  and  galvanize  the  knee.  If  in  any  case  there  existed 
evidence  of  displacement,  whether  of  cartilage  or  bone,  the 
limb  should  be  extended,  flexed,  and  rotated,  until  the  parts 
displaced  resumed  their  proper  positions  and  functions.  I 
have  seemingly  relieved  a  difficulty  of  this  kind  by  flexing  the 
knee  to  its  utmost,  then  suddenly  straightening  the  limb,  re- 
peating the  operation  with  the  addition  of  a  slight  rotatory 
movement.  "  Natural  bone-setters"  have  occasionally  gained 
great  advantages  by  imparting  to  a  disordered  joint  certain 
movements  of  this  kind. 

Whether  anything  like  reduction  is  effected  or  not,  some 
degree  of  syuovitis  will  attend  the  injury,  which  needs  to  be 


396  DISLOCATIONS. 

subdued  by  proper  management.  As  all  such  difficulties  of 
the  joint  are  liable  to  be  repeated  sooner  or  later,  an  elastic 
knee-cap  should  be  worn  for  months  or  even  years. 

Compound  dislocation  of  the  knee  is  one  of  the  most  danger- 
ous accidents  that  occur  to  a  limb.  Besides  the  injury  to  tbe 
soft  parts,  which  must  be  considerable,  large  articular  surfaces 
are  exposed  to  the  influences  of  the  air,  and  subjected  to  those 
changes  which  begin  in  shock  and  end  in  suppuration.  The 
popliteal  artery,  veins  and  nerves,  are  stretched,  or  torn,  so 
that  complications  of  the  most  dangerous  character  can  scarcely 
be  escaped.  In  most  instances  it  would  not  be  advisable  to 
attempt  to  save  the  limb  ;  though,  if  the  subject  of  the  acci- 
dent be  vigorous,  and  the  vessels  and  nerves  apparently  not 
much  injured,  an  attempt  to  save  the  limb  would  be  justifiable. 
However,  the  entreaties  of  the  patient  or  those  of  his  friends, 
who  can  not  comprehend  the  extreme  dangers  of  a  compound 
dislocation  of  the  knee,  should  not,  in  a  severe  case,  deter  the 
surgeon  from  expressing  his  views  in  decisive  terms,  nor 
swerve  him  from  his  plain  path  of  duty.  Many  a  timid, 
vacillating,  or  too  easily  influenced  surgeon  has,  when  too 
late,  regretted  having  trusted  to  the  recuperative  powers  of 
nature  in  severe  injuries  of  the  knee-joint.  Amputation,  or 
even  resection, seems  a  harsh  and  uncompromising  measure  to 
adopt  in  case  of  compound  dislocation  of  the  tibio-femoral 
articulation,  yet  the  more  experience  a  surgeon  has  the  le^a 
he  is  disposed  to  trust  to  any  conservative  course  in  the  man- 
agement of  compound  lesions  of  the  knee. 


CHAPTER    XIV. 
DISLOCATION  OF  THE  TIBIO-FIBULAR  ARTICULATIONS. 


Separation  of  the  tibio-fibular  connections  must  be  ex- 
tremely rare,  for  two  principal  reasons:  1st,  no  considerable 
force  can  be  so  directed  as  to  tell  effectively  towards  separating 
these  bones ;  and  2ndly,  the  interosseous  ligament,  together 
with  the  ligamentous  fastenings  between  the  tibia  and  fibula 
near  the  extremities  of  these  bones,  render  their  disjunction 
exceedingly  difficult.  If  all  the  ligaments  connecting  these 
two  bones  be  preternatu  rally  relaxed  some  displacement  of 
the  fibula  would  be  admissible,  without,  however,  presenting 
a  dislocation  in  the  ordinary  acceptation  of  the  term.  Dislo- 
cation of  either  end  of  the  fibula  may  attend  a  fracture  of 
the  tibia ;  but  as  a  distinct  lesion,  unaccompanied  with  frac- 
ture, the  fibula  is  seldom,  disengaged  from  its  articular  rela- 
tions with  the  tibia  at  either  of  its  extremities.  The  upper 
end  of  the  fibula  is  reported  to  have  been  displaced  forwards 
and  backwards. 

In  the  forward  dislocation,  three  or  four  examples  of  which 
have  been  collected,  there  was  doubt  whether  muscular  action 
or  direct  violence  produced  the  displacement,  though  it  is 
probable  that  the  latter  cause  was  the  true  one,  inasmuch  as 
little  muscular  force  can  be  exerted  in  the  forward  direction 
upon  the  upper  extremity  of  that  bone.  In  the  extreme 
flexed  state  of  the  limb,  as  in  a  squatting  attitude,  the  thigh 
presses  the  upper  end  of  the  fibula  forwards,  and  the  muscles 
arising  from  the  anterior  aspect  of  the  upper  half  of  the  bone, 
also  tend  to  displace  it  forwards.  With  these  forces  at  work, 
and  a  direct  blow  coming  at  the  same  time,  the  head  of  the 
fibula  might  be  thrown  in  front  of  its  normal  position. 

(397) 


398  DISLOCATIONS. 

TLe  signs  of  this  displacement  are  tolerably  plain.  The 
head  of  the  iibula  is  not  in  its  natural  position,  but  its  pres- 
ence is  discoverable  near  the  ligamentum  patellse ;  the  biceps 
flexor  cruris,  which  is  inserted  into  the  head  of  the  bone,  is 
put  upon  the  stretch;  and  the  natural  contour  of  the  leg  just 
below  the  knee,  is  lost. 

TREATMENT. — Dislocation  of  the  head  of  the  fibula  forward, 
is  reduced  by  extending  the  leg  and  rotating  the  foot  out- 
wards, the  surgeon  at  the  same  time  pressing  the  bone  back 
into  its  natural  position.  Rest  for  a  couple  of  weeks  will 
allow  the  torn  ligaments  time  to  heal. 

Dislocation  of  the  upper  end  of  the  fibula  backwards  is  a 
rarer  accident  than  the  forward  displacement.  Direct  violence 
is  the  chief  cause,  though  the  action  of  the  external  hnin- 
string  muscle  might  assist  in  the  luxation.  Malgaigne  has 
reported  a  case  or  two  in  which  muscular  action  and  direct 
force  seemed  to  have  produced  the  displacement.  The  head 
of  the  fibula  was  thrown  behind  its  usual  position,  and  could 
there  be  distinctly  felt  beneath  the  skin.  The  reduction  is 
accomplished  by  flexing  the  leg  to  relax  the  biceps,  and  then 
the  bone  may  be  pushed  into  its  normal  place.  Unless  the 
leg  is  kept  flexed  at  the  knee  for  two  or  three  weeks  there  is 
danger  that  the  luxation  may  be  reproduced.  A  compress 
bound  against  the  posterior  aspect  of  the  bone,  will  assist  in 
keeping  the  head  of  the  fibula  in  its  natural  position. 

Dislocation  of  the  lower  end  of  the  fibula  from  its  tibial 
connection  has  been  reported.  The  displacing  force  of  a 
passing  wheel,  might  throw  the  lower  end  of  the  fibula  back 
toward  the  tendo-Achillis ;  and  a  similar  force  acting  upon 
the  bone  while  the  leg  was  resting  upon  its  anterior  aspect 
might  possibly  effect  a  forward  displacement.  Either  variety 
of  luxation  would  be  difficult  to  overcome.  While  the  foot 
was  rocked  inwards  the  surgeon  should  make  an  effort  to 
push  or  pull  the  bone  into  place.  Once  restored  to  its  natural 
position  there  would  be  no  particular  danger  of  a  reproduc- 
tion of  the  lesion. 


CHAPTER  XV. 
DISLOCATION  OF  THE  ANKLE-JOINT 


Following  the  nomenclature  heretofore  adopted,  luxations 
at  the  ankle  will  not  be  regarded  as  dislocations  of  the  lower 
end  of  the  tibia.  In  all  other  dislocations  the  distal  part  of 
the  limb  is  assumed  to  be  displaced,  though  it  may  not  be 
strictly  correct  in  all  instances.  The  foot  may  be  held  fixed, 
and  a  displacing  force  throw  the  tibia  forward  on  the  astraga- 
lus, the  tibia  being  the  bone  displaced:  the  same  thing  may 
happen  to  other  joints.  For  example,  the  arm  maybe  caught 
and  held  immovably,  while  a  force  twists  the  body  until  the 
scapula  is  displaced  from  the  head  of  the  humerus.  This  cir- 
cumstance does  not  do  away  with  the  fact  that  the  injury,  so 
far  as  surgical  recognition  is  concerned,  is  a  dislocation  of  the 
humerus.  Those  who  contend  for  exceptions  to  ordinay  rules, 
as  applied  to  dislocations,  gain  nothing,  and  contribute  their 
support  to  what  can  be  correct  only  a  part  of  the  time.  In- 
deed, in  not  a  few  instances  neither  form  of  language  could 
be  strictly  correct,  for  the  displacement  is  mutual,  i.  <?.,  a 
double  force  produces  the  dislocation, — one  drives  the  tibia 
forwards,  for  example,  and  the  other  propels  the  astragalus 
backwards  in  the  same  accident.  It  is  absurd,  then,  to  destroy 
the  harmony  of  nomenclature  by  adherence  to  an  exception 
which  presents  no  compensating  advantages. 

Dislocations  of  the  foot  at  the  ankle-joint  take  place  in  four 
directions ;  and,  mentioned  in  the  order  of  frequency,  they 
stand  as  follows  :  outwards,  inwards,  backwards,  and  forwards. 

In  the  outward  dislocation,  the  injury  is  commonly  compli- 
cated with  a  fracture  of  the  fibula  a  few  inches  above  the 
malleolus.  The  foot  is  strongly  everted,  the  outer  edge  of  the 
sole  being  elevated,  and  the  inner  resting  on  the  ground.  A 

(399) 


400 


DISLOCATIONS. 


Fia.  126. 


depression    exist-*    at    the  seat  of  fracture,  and  the  internal 
malleolus  projects  prominently. 

The  injury  is  produced  by  a  violent  twist  or  wrench  of  the 
foot  outwards,  as  in  stepping  on  the  outer  edge  of  the  foot  the 

sole  comes  down  upon  a  roll- 
ing stone  or  a  projection  of 
frozen  earth.  It  is  often  caused 
by  a  fall,  the  weight  of  the 
body  being  received  on  the 
outer  half  of  the  sole,  giving 
the  leg  a  cant  inwards.  This 
injury  has  already  been  de- 
scribed in  the  chapter  on  fnu-- 
tures  of  the  fibula;  one  part 
of  the  accident  rarely  occurs 
except  in  combination  with 
the  other.  In  extremely  rare 
instances,  the  fibula  may  lie 
broken  just  above  the  ankle- 
joint,  without  dislocation  of 
the  astragalus  ;  and  occasion- 
ally the  foot  may  be  luxated, 
partially  or  completely,  with- 
out the  fibula  being  broken.  However,  the  double  form  of 
injury  is  to  be  expected  in  the  majority  of  cases.  Besides  the 
fracture  of  the  fibula,  either  the  internal  malleolus  is  broken, 
or  the  internal  lateral  ligament  (deltoid)  is  torn.  If  the  lower 
end  of  the  tibia  be  broken,  as  well  as  the  fibula,  and  the  foot 
thrown  outwards  with  these  two  inferior  fragments,  the  injury 
is  not  legitimately  a  dislocation,  but  a  fracture  of  both  bones 
of  the  leg.  Boyer  relates  a  singular  case  in  which  the  dislo- 
cation of  the  foot  was  not  attended  with  fracture  of  the  fibula, 
but  with  displacement  of  that  bone  at  its  upper  extremity. 
It  is  possible  for  the  foot  to  be  thrown  outwards,  the  fibula 
not  suffering  fracture  but  separation  from  the  tibia  at  the 
peroneo-tibial  articulation.  Such  accidents  have  occurred,  un- 
less there  has  been  some  mistake  on  the  part  of  those  who 
reported  them. 

The  ordinary  form  of  the  accident  is  sometimes  adjusted  by 
the  patient  before  the  surgeon  has  an  opportunity  to  examine 
the  parts  implicated  in  the  accident.  Finding  his  foot  in  an 


Dislocation  of  the  foot  outwards. 


OF  THE  ANKLE-JOINT.  401 

awkward  state-  of  deformity,  the  patient  reaches  down  and 
twists  it  back  into  place;  and  then  after  being'  carried  home, 
he  lias  his  ankle  bathed  in  liniments,  believing  the  injury  only 
a  sprain,  and  does  not  send  for  a  surgeon  until  he  finds  that 
the  difficulty  is  more  serious  and  tedious  than  at  first  antici- 
pated. Called  several  days  after  the  accident  and  the  return 
of  the  foot  to  nearly  its  natural  position,  the  surgeon  must  not 
be  misled  by  the  patient's  opinion  of  the  case;  but  should 
seek  the  depression  in  the  course  of  the  fibula  an  inch  or  two 
above  the  ankle,  and  rotate  the  foot  to  elicit  crepitation. 
Though  the  parts  be  swollen,  a  careful  examination  will  reveal 
the  nature  of  the  injury.  If  asked  the  question,  the  patient 
will  remember  having,  with  his  own  hands,  twisted  the  dis- 
torted foot  into  position.  In  the  event  of  dislocation,  without 
fracture  of  the  fibula,  the  reduction  is  too  difficult  for  the 
patient  to  accomplish,  and  the  surgeon  will  then  find  the  parts 
involved  in  the  injury  just  as  the  accident  left  them. 

TKEATMENT. — The  outward  dislocation  of  the  ankle,  as  has 
already  been  intimated,  is  not  difficult  to  overcome.  In  most 
cases  the  surgeon,  after  flexing  the  leg  on  the  thigh  to  relax 
the  gastrocnemius,  can  with  his  hands  press  the  foot  into  its 
natural  position.  It  may  facilitate  the  operation  by  gently 
rocking  the  foot  while  moderate  extending  force  is  applied. 
After  reduction  is  accomplished,  two  side  splints  are  to  be 
used,  with  a  compress  between  the  lower  end  of  the  outside 
splint  and  the  external  malleolus,  or  the  outside  of  the  foot 
just  below  the  malleolus,  as  recommended  in  the  treatment 
of  "Pott's  fracture"  of  the  fibula.  In  some  instances,  where 
the  internal  lateral  ligament  is  torn  across,  as  it  generally  is, 
the  ankle  will  remain  weak,  with  a  tendency  for  the  foot  to 
turn  out  too  much,  especially  when  a  step  is  made  upon  an 
uneven  surface. 

Hamilton  reports  two  cases  in  his  work  on  Fractures  and 
Dislocations,  in  which  the  reduction  could  not  be  effected  on 
account  of  some  obstacle  in  the  articulation,  which  may  have 
arisen  from  fracture  of  the  lower  extremity  of  the  tibia,  the 
small  fragment  being  in  the  way  of  reduction.  He  also  re- 
ports having  amputated  the  limb  for  compound  dislocation  of 
the  foot  outwards  ;  and  a  dissection  exhibited  a  fracture  of 
the  outer  part  of  the  articular  surface  of  the  tibia,  the  wedge- 
26 


402  DISLOCATIONS. 

shaped  fragment  occupying  a  position  in  the  joint  adverse  to 
reduction. 

When  the  top  of  the  astragalus  has  slipped  away  from  the 
articulating  surface  of  the  tibia,  and  lodged  in  the  channel 
between  that  bone  and  the  outwardly  displaced  external  mal- 
leolus,  the  reduction  can  not  be  exceedingly  difficult  to  effect; 
and  if  the  displacement  could  not  be  overcome  by  ordinary 
means,  the  inference  would  be  that  a  piece  of  the  outer  side 
of  the  tibia  had  been  chipped  off,  and  dropped  down  between 
the  astragalus  and  the  main  fragment  of  the  tibia,  either 
maintaining  the  upright  attitude  or  turning  over  upon  its  side 
and  becoming  au  obstacle  in  the  capacity  of  a  Avedge. 

The  dislocation  of  the  ankle  inwards  is  a  rare  accident,  and 
must  occur  from  a  forcible  rocking  of  the  foot  upon  its  axis 
in  a  direction  calculated  to  split  off  the  internal  malleolus,  and 
to  stretch  and  tear  the  external  lateral  ligaments  of  the  joint. 
In  this  injury  the  foot  is  thrust  inwards,  so  that  the  outer  edge 
of  the  sole  meets  the  ground,  and  the  inner  edge  is  raised, 
making  the  bottom  of  the  foot  present  toward  the  opposite 
foot.  The  lower  end  of  the  fibula,  or  the  external  malleolus, 
projects  very  prominently  ;  the  width  of  the  joint  is  increased  ; 
mid  the  internal  malleolus  is  displaced  and  moves  with  the  as- 
tragalus. In  a  case  that  recently  came  under  my  observation, 
the  internal  malleolus  was  broken,  and  the  fibula  was  fractured 
three  inches  above  its  lower  extremity.  If  I  had  not  seen  the 
deformity  before  it  was  overcome,  I  should  have  been  disposed 
to  believe  that  the  luxation  had  been  originally  outwards,  and 
that  in  the  efforts  at  reduction,  the  foot  had  been  rotated  too 
far  inwards.  The  accident  happened  by  a  fall  from  a  building, 
the  foot  striking  among  some  rubbish.  It  is  not  improbable 
that  the  displacement  was  primarily  outwards,  breaking  the 
fibula  above  the  ankle,  and  the  internal  malleolus,  by  the 
strain  on  the  deltoid  ligament;  and  that  by  a  further  descent 
of  the  body  the  foot  received  an  inward  cant  which  threw  it  in 
that  direction  beyond  its  usual  limit. 

TREATMENT. — The  inward  dislocation  of  the  ankle  is  always 
reduced  with  ease.  If  the  patient  lias  not  turned  the  foot 
into  place  with  his  own  hands,  the  surgeon  has  only  to  seize 
the  foot  and  make  extension,  at  the  same  time  rotating  it  out- 
wards. !N"o  powerful  forces  are  required  to  replace  the  luxated 
bones,  or  to  adjust  the  displaced  fragments.  The  healing  pro- 


OF  THE  ANKLE-JOINT. 


403 


FIG.  127. 


cess  will  occupy  four  or  five  weeks,  and  during  this  time  the 
two  leg  splints  should  be  worn,  with  a  compress  between  the 
inside  of  the  foot,  below  the  malleolus,  and  the  lower  end  of 
the  splint.  Any  rotation  or  distortion  of  the  foot  is  to  be 
corrected  during  the  time  the  dressing  is  worn,  by  the  judicious 
use  of  adhesive  strips,  which  in  their  application  are  to  begin 
at  the  base  of  the  great  toe  and  cross  the  hollow  of  the  foot 
obliquely,  along  the  course  of  the  peroueus  longus  muscir. 
and  thence  over  the  external  malleolus  and  up  the  leg  on  its 
anterior  aspect.  The  position  of  the  foot  can  be  regulated  by 
the  proper  employment  of  strips  of  adhesive  plaster,  even  if 
no  splints  be  applied,  though  the  use  of  splints  keeps  the  ankle 
from  turning  laterally  in  either  direction.  If  the  fragment 
embracing  the  internal  malleolus  unites  to  the  rest  of  the  bone 
by  osseous  consolidation,  the  cure  will  generally  be  satisfac- 
tory ;  but  if  it  make  only  a  ligamentous  connection  the  ankle 
must  always  remain  weak. 

Dislocation  of  the  foot  backwards 
may  take  place  in  a  leap  from  a  car- 
riage in  motion,  or  from  a  fall  in 
which  the  heel  catches  or  the  toes 
meet  something  solid,  the  impetus 
of  the  body  carrying  the  leg  for- 
wards. The  displacement  is  gener- 
ally accompanied  with  a  fracture  of 
the  fibula  just  above  the  ankle,  the 
lower  fragment,  constituting  the  ex- 
ternal malleolus,  remaining  in  con- 
tact with  the  astragalus.  The  tibia 
takes  a  position  in  front  of  the  as- 
tragalus, on  the  navicular  and  cunei- 
form bones. 

The  symptoms  of  this  accident 
are  a  shortening  of  the  anterior  part 
of  the  foot  and  a  lengthening  of  the  heel.  The  toes  are 
pointed  downwards,  and  the  extremity  of  the  tibia  forms  a 
projection  in  front  of  the  ankle.  The  tendo-Achillis  is  arched, 
and  the  tendons  on  the  top  of  the  foot  are  tense  and  sharply 
defined. 

TREATMENT. — This  variety  of  dislocation   is  commonly  re- 
duced without  much  difficulty,  though  considerable  extending 


I>i-lwation  of  the  foot  backwards: 


404  DISLOCATIONS. 

force  is  required  before  the  boues  of  the  leg  and  foot  can  be 
pulled  and  pushed  into  their  proper  positions.  The  flexing 
of  the  leg  on  the  thigh  relaxes  the  gastrocuemius  muscle, 
therefore  an  assistant  should  put  his  arm  under  the  lower  ex- 
tremity of  the  thigh,  to  make  counter-extension,  while  the 
surgeon  makes  extension  with  one  hand  on  the  patient's  heel 
and  the  other  on  his  toes.  The  dressing  and  after-treatment 
should  be  much  like  that  recommended  for  treating  the  lateral 
dislocations  of  the  ankle.  Due  regard  must  be  exercised  for 
the  fracture  of  the  fibula. 

In  some  cases  it  may  be  found  difficult  to  maintain  the  parts 
in  place  after  reduction  is  accomplished.  However,  if  the  foot 
is  kept  flexed  on  the  leg,  and  the  heel  made  to  support  the 
weight  of  the  limb,  the  tendency  to  displacement  is  mostly 
overcome.  In  cases  where  the  heel  will  endure  press  are.  and 
the  anterior  part  of  the  leg  near  the  ankle,  some  additional  re- 
tentive means  may  be  employed.  If  the  foot  and  leg  be  placed 
in  a  box,  with  the  heel  suspended  on  a  strip  of  buckskin,  an- 
other strip  of  the  same  material  may  be  made  to  press  on  the 
front  of  the  leg  by  passing  the  ends  through  two  holes  bored 
in  the  sides  of  the  box  below  the  level  of  the  limb,  and  then 
tied  over  the  top  of  the  box.  Great  watchfulness  is  needed 
to  prevent  a  slough  of  the  heel,  for  such  a  complication  is  fre- 
quent, and  its  effects  tedious  and  distressing. 

Dislocation  ot  the  foot  forwards  is  the  rarest  form  of  dis- 
placement occurring  at  the  ankle-joint.  The  injury  arises 
mostly  from  falls,  the  foot  meeting  the  ground  with  the  toes 
elevated,  and  there  remaining  fixed  while  the  descent  of  the 
body  carries  the  leg  bones  down  behind  the  summit  of  the  as- 
tragalus. One  of  the  best  described  cases  is  that  of  Mr.  R. 
"W.  Smith,  in  the  Dublin  Quarterly  Journal  of  Medical  Science, 
for  May,  1852.  The  subject  of  the  accident  was  a  sailor,  who, 
while  assisting  to  raise  a  very  heavy  cask  on  board  ship,  hav- 
ing at  the  same  time  one  leg  much  flexed  on  the  foot,  and  the 
thigh  on  the  leg,  was  struck  by  the  falling  of  a  cask  just  above 
the  knee,  forcing  the  distal  end  of  the  tibia  backwards  from 
off  the  astragalus  on  the  upper  and  posterior  surface  of  the 
calcaneum.  The  symptoms  of  this  accident  were,  a  lengthen- 
ing of  the  dorsum  of  the  foot  to  the  extent  of  one  inch,  and  a 
shortening  of  the  leg  to  the  extent  of  half  an  inch,  the  two 
malleoli  being  so  much  nearer  the  ground.  The  projection  of 


OF  THE  ANKLE-JOINT.  405 

the  heel  had  disappeared,  and  the  tibia  formed  a  remarkable 
projection  iu  front  and  to  the  inner  side  of  the  tendo-Achillis. 
The  fibula,  was  uninjured;  but  the  extremity  of  the  inner 
malleolus  received  a  fracture. 

The  only  accident  with  which  this  could  be  confounded  is  a 
fracture  of  the  tibia  immediately  above  the  ankle-joint ;  but 
the  situation  of  the  malleoli  would  be  decisive  of  the  nature 
of  the  injury.  "In  the  few  cases  of  this  accident  which  have 
been  published,"  says  Mr.  Carsteu  Holthouse,  "reduction  was 
not  effected,  and  the  patients  remained  very  lame ;  but  there 
seems  to  be  no  reason  why  cases  of  this  description,  if  seen 
early  and  properly  recognized,  should  not  be  reduced  in  a 
similar  manner  to  the  lateral  dislocations,  and  treated  in  all 
respects  similarly." 

A  dislocation  of  the  foot  forwards  could  not  take  place 
without  extensive  laceration  of  nearly  all  the  ligamentous 
structures  about  the  joint;  and  the  tendons  passing  behind 
the  two  malleoli  are  put  greatly  upon  the  stretch,  and  may 
drop  from  their  sheaths  into  the  mortise-like  excavation  usually 
occupied  by  the  astragalus. 

TREATMENT. — The  forward  luxation  of  the  foot  can  not  be 
overcome  without  well-directed  and  vigorous  efforts  on  the 
part  of  the  surgeon  and  assistants.  The  aid  of  chloroform  in 
relaxing  the  muscles  is  invaluable  ;  and  the  patient  should  be 
made  to  take  the  agent  until  he  is  profoundly  under  its 
influence.  The  injured  limb  should  then  be  flexed  at  the 
knee,  and  held  by  an  assistant;  the  foot  is  to  be  extended  by 
the  hands  of  another  assistant;  and  the  surgeon  pulls  the  leg 
forwards  and  pushes  the  foot  backwards.  If  several  efforts  of 
this  kind  prove  unsuccessful,  the  most  unyielding  tendons  may 
be  divided  subcutaneously,  to  facilitate  the  reduction.  Once 
in  place,  great  care  must  be  exercised  to  prevent  a  recurrence 
of  displacement.  The  weight  of  the  limb  must  not  rest  on 
the  heel,  but  on  the  leg  above  the  ankle.  The  limb  should  be 
kept  at  rest  for  several  weeks,  or  until  it  is  presumed  that  the 
torn  ligaments  have  united. 


CHAPTER  XVI. 


Says  Mr.  Robert  Wm.  Smith,  in  his  Treatise  on  Fractures? 
/•/''.,  "  The  mechanism  by  which  the  bones  of  the  foot  are 
secured  against  the  effects  of  external  violence,  is  so  complete 
and  powerful,  that  we  seldom  have  opportunities  of  witness- 
ing luxations  of  the  bones  of  the  tarsus  from  one  another,  or 
their  displacement  from  the  metatarsal  range." 

The  os  calcis  has  been  dislocated  from  its  relations  with  the 
astragalus,  and  in  the  same  injury  the  scaphoid  bone  has  been 
disconnected  from  its  astragaloid  relations,  these  bones  with 
the  rest  of  the  foot  going  backwards,  causing  the  head  of  the 
astragalus  to  take  a  position  upon  the  instep,  where  it  forms 
a  tumor,  projecting  almost  through  the  skin.  The  foot  is 
shortened  in  front  of  the  leg,  and  the  heel  is  elongated.  An 
example  of  this  injury  is  reported  by  Macdonnell,  in  the 
Dublin  Journal.  On  the  6th  of  August,  1838,  Mr.  Carmichael 
was  riding  at  a  brisk  trot  when  his  horse  suddenly  fell.  To 
prevent  being  pitched  forwards,  he  threw  himself  back  in  the 
saddle,  and  strongly  extended  his  legs  to  meet  the  ground. 
The  shock  of  this  descent  was  accordingly  received  upon  the 
anterior  extremities  of  the  metatarsal  bones,  especially  the 
metatarsal  bone  of  the  great  toe  of  the  right  foot,  which  alone 
came  to  the  ground.  The  following  were  the  symptoms: 
"  The  toes  were  turned  outwards,  the  inner  edge  of  the  foot 
forming  an  angle  of  about  30°  with  its  natural  direction  ;  the 
sole  was  slightly  turned  outwards,  and  the  outer  edge  slightly 
elevated.  The  concavity  of  the  teudo-Achiilis  posteriorly 
was  manifestly  increased,  and  the  heel  lengthened.  ( )u  grasp- 
ing the  soft  parts  between  the  tendo-Achillis  and  tibia,  we 
found  the  distance  between  these  parts  much  greater  than  in 
the  other  foot.  The  absence  of  the  hard  projection,  which 

(406) 


OF    THE    BOXES  OF  THE   FOOT.  407 

would  have  beeii  formed  by  the  upper  articulating  surface  of 
the  astragalus,  had  it  passed  backwards  with  the  other  tarsal 
bones,  was  evident.  The  malleoli  were  perfectly  defined. 
J3elow  and  before  the  inner  there  was  a  hard  prominence,  over 
which  the  skin  was  tense,  formed  by  the  inner  surface  of  the 
astragalus  brought  into  relief  by  the  dislocation,  and  the  slight 
e version  of  the  sole  of  the  foot.  Much  the  most  striking  part 
of  the  deformity  consisted  in  a  prominence  on  the  dorsum  of 
the  foot.  Immediately  in  front  of  the  tibia  it  presented  a  flat 
surface  broad  enough  to  receive  the  linger,  and  from  which 
there  was  an  abrupt  descent  upon  the  anterior  part  of  the  tar- 
sus. Over  this  projection,  caused  by  the  head  of  the  astraga- 
lus, the  integuments  were  so  tense  that  it  was  evident  a  very 
small  additional  force  would  have  driven  it  through  the  skin. 
Lastly,  on  taking  the  distance  from  the  point  of  the  internal 
malleolus  to  the  extremity  of  the  great  toe  with  a  tape- 
measure,  I  found  it  to  be  nearly  exactly  an  inch  less  than  the 
distance  between  the  same  points  in  the  left  foot.  We  could 
detect  no  fracture.  The  foot  could  be  flexed  and  extended, 
but  it  occasioned  great  pain."  To  understand  this  dislocation 
better,  it  must  be  considered  that  the  astragalus  retains  its 
normal  connections  with  the  tibia  and  external  malleolus,  and 
becomes  disconnected  from  the  calcaneum  and  scaphoid  bones, 
they  passing  backwards. 

The  reduction  of  such  a  dislocation  is  to  be  effected  by  the 
strength  of  the  surgeon's  hands,  the  patient  being  anaesthe- 
tized, and  his  leg  flexed  and  managed  bj  an  assistant,  who 
pulls  the  tibia,  fibula,  and  astragalus  backwards,  and  the  sur- 
geon, with  one  hand  on  the  patient's  heel  and  the  other  on  his 
instep,  exerts  extension  and  a  forward  movement  of  the  foot. 
Some  twisting  and  rotation  of  the  foot  facilitate  the  return 
of  the  displaced  bones  to  their  normal  relations. 

Dislocation  of  the  calcaneum  and  the  other  bones  of  the 
foot  forwards,  the  astragalus  alone  being  left  in  connection 
with  the  bones  of  the  leg,  is  an  exceedingly  uncommon  acci- 
dent. Malgaigne  finds  but  one  example,  and  that  is  reported 
by  M.  Varise.  The  injury  happened  to  a  quarryman  who, 
while  at  work,  with  his  left  foot  resting  on  a  block  of  stone, 
and  his  right  on  the  ground,  was  thrown  forcibly  forwards  by 
the  falling  of  a  mass  of  stone  ;  the  thigh  being  at  the  same 
time  strongly  Hexed  on  the  trunk,  the  leg  on  the  thigh,  and 


408  DISLOCATIONS. 

the  foot  on  the  leg.  The  following  symptoms  were  observed  : 
the  foot  was  flexed ;  the  projection  of  the  heel  had  disap- 
peared ;  and  the  bones  of  the  leg  with  the  astragalus  in  its 
normal  relation  with  them,  were  found  behind  the  calcaneum, 
or  were  resting  upon  its  posterior  extremity.  As  no  crepitus 
was  discoverable  it  was  presumed  that  the  injury  was  a  dislo- 
cation ;  but  the  pain  and  the  swelling  were  so  great,  that  a 
complete  examination  could  not  be  made,  and  reduction  was 
not  attempted.  Nine  mouths  afterwards  the  condition  of  the 
limb  was  as  follows :  the  foot  was  flexed  at  a  right  angle 
with  the  leg,  its  point  inclined  inwards,  and  its  inner  border 
slightly  depressed;  it  was  elongated  in  front  of  the  bones  of 
the  leg,  and  the  projection  of  the  heel  was  completely  effaced. 
At  the  level  of,  and  a  little  below  the  malleoli,  posteriorly, 
was  a  bony  projection,  which  pushed  backwards  the  tendo- 
Achillis  beyond  the  heel.  Above  this  projection  there  was 
another  less  marked,  formed  by  the  posterior  and  inferior 
margin  of  the  tibia ;  the  malleoli  were  not  separated  from 
each  other,  nor  did  they  present  any  traces  of  fracture.  The 
extensor  tendons  of  the  toes  were  stretched  over  the  instep, 
and  beneath  these  on  the  outer  side  was  a  projection,  which 
appeared  to  be  the  head  of  the  astragalus,  and  immediately 
in  front  of  this  a  depression.  Flexion  and  extension  of  the 
ankle-joint  existed  to  a  limited  extent. 

It  is  possible  that  this  displacement  could  not  be  overcome, 
but  if  chloroform  had  been  administered,  it  is  quite  probable 
that  a  surgeon  to  pull  the  foot  backwards,  and  an  assistant  to 
pull  the  leg  forwards,  might  have  accomplished  reduction. 
Flexion  of  the  leg  and  extension  of  the  foot,  would  favor  a 
return  of  the  bones  to  their  accustomed  places. 

Dislocation  of  the  foot  sideways  at  the  calcaneo-astragaloid 
joint,  is  apt  to  be  incomplete  and  compound  ;  the  astragalus 
rests  on  a  portion  of  the  os  calcis,  and  is  not  thrown  upon  its 
side,  as  it  would  be  if  the  dislocation  were  complete.  Forced 
adduction  and  abduction  are  the  principal  causes  of  these 
lateral  dislocations  of  the  caloaneum. 

In  the  outward  dislocation  the  foot  is  abducted,  the  outer 
border  of  the  sole  being  raised,  and  the  inner  resting  on  the 
ground.  The  external  malleolus  is  buried  in  the  fossa  caused 
by  the  eversion  of  the  foot,  and  the  inner  malloolus  and  the 
head  of  the  astragalus  project  unnaturally  inwards.  In  thir- 


OF  THE  BONES  OF  THE  FOOT.  409 

teen  examples  of  this  variety  of  dislocation  collected  by  Broca, 
nine  were  compound,  and  in  six  the  fibula  was  broken. 

,  The  inward  dislocation  at  the  calcaneo-astragaloid  joint, 
presents  deformities  similar  to  the  varus  form  of  club-foot ; 
the  foot  is  inverted,  and  its  inner  border  raised.  The  head  of 
the  astragalus  and  the  external  malleolus  project  beyond  the 
outer  border  of  the  foot,  and  a  deep  depression  exists  below. 
On  the  inside  of  the  foot  an  elongated  projection,  formed  by 
the  inner  border  of  the  calcaneum,  completely  masks  the  in- 
ternal malleolus.  The  scaphoid  bone  can  be  felt  nearer  to  the 
os  calcis  than  natural,  and  thus  the  inner  border  of  the  foot  is 
shortened  and  rendered  somewhat  concave,  while  the  outer  is 
lengthened  and  made  unnaturally  convex. 

The  widest  difference  seems  to  exist  in  the  difficulties  en- 
countered by  the  several  surgeons  who  have  reported  cases  of 
dislocation  of  the  bones  of  the  tarsus.  Probably  the  kind 
and  degree  of  displacement  are  not  always  the  same  ;  and  it 
is  possible  that  all  cases  were  not  managed  with  the  same 
amount  of  intelligence  and  perseverance.  In  not  a  fe\v  in- 
stances the  ligaments  of  the  tarsus,  and  the  tendons  passing 
from  the  leg  to  their  insertions  in  the  foot,  act  as  mechanical 
impediments  to  the  return  of  the  displaced  bones;  in  ex- 
tremely rare  cases,  they  may  become  insuperable  obstacles  to 
reduction.  In  those  cases  in  which  it  is  apparent  that  the 
tendons  offer  the  principal  resistance  to  reduction,  it  is  advis- 
able to  divide  subcutaneously  the  tendo-Achillis,  and  perhaps 
the  tibialis  anticus  and  posticns. 

In  some  dislocations  about  the  foot  and  ankle  it  is  ex- 
tremely difficult  to  determine  the  exact  nature  of  the  injury, 
one  lesion  so  much  resembles  another.  There  are  deformities 
attendant  upon  fractures  in  the  immediate  vicinity  of  the 
ankle,  that  appear  like  those  following  luxations  of  the  bones 
of  the  tarsus,  therefore  the  surgeon -should  exercise  his  powers 
of  discrimination  if  he  would  escape  making  a  faulty  diag- 
nosis. Those  injuries  which  are  compound,  do  not  present  so 
many  difficulties  in  the  way  of  a  correct  solution  of  the  mys- 
tery. It  would  not  ordinarily  be  easy  to  diagnose  a  rotation 
of  the  astragalus,  in  which  the  upper  or  trochlear  surface  pre- 
sented inwards,  and  its  outer  surface  upwards  ;  but  it'  the  ac- 
cident leave  an  opening  to  the  bone  the  insertion  of  the  finger 
might  determine  exactly  the  nature  of  the  displacement. 


410  DISLOCATIONS. 

According  to  the  results  of  cases  collected  by  M.  Broca.  it 
is  much  safer  to  let  a  dislocated  tarsal  bone,  which  can  not  be 
reduced,  remain  in  its  abnormal  position  than  to  attempt  to 
remove  it;  and  amputation,  which  has  so  many  times  been 
adopted  at  once  after  some  of  the  tarsal  dislocations,  should 
not  be  considered  as  long  as  there  existed  a  possibility  of  es- 
caping gangrene,  and  other  serious  complications.  In  acci- 
dents of  a  crushing  character,  breaking  and  displacing  the 
bones,  and  compounding  the  injury  by  lacerating  the  soft  tis- 
sues, no  special  rules  can  be  given  which  would  be  generally 
applicable,  yet  in  the  management  of  such  injuries,  the  accom- 
plished surgeon  who  is  accustomed  to  act  in  emergencies,  and 
is  governed  by  the  general  principles  of  his  science,  knows  as 
well  what  the  necessities  of  each  particular  case  demand,  as 
if  he  had  just  studied  a  written  direction  for  the  treatment 
of  such  a  case. 

The  astragalus,  when  it  is  displaced,  may  become  so  com- 
pletely isolated  from  nutritive  connections,  as  to  be  in  danger 
of  necrosis.  Under  such  circumstances,  it  would  be  better  to 
extract  the  bone  at  once,  than  to  leave  it  where  by  prolonged 
irritation  it  might  jeopardize  the  limb,  or  even  the  life  of  the 
patient. 

Mr.  Burnett,  in  the  London  Medical  Gazette,  for  1837,  de- 
scribes the  case  of  a  gentleman  who,  in  taking  a  leap  while 
fox-hunting,  dislocated  the  scaphoid  bone  from  its  connections 
with  the  cuneiform  bones.  A  wound  three  inches  in  length 
was  made  in  the  instep  through  which  the  scaphoid  and  part. 
of  the  astragalus  protruded.  By  making  steady  pressure  on 
the  bone  for  fifteen  minutes  it  was  reduced.  The  wound 
healed,  and  the  patient  recovered  the  free  use  of  the  foot. 
Piedagnel  was  unable  to  reduce  a  displaced  scaphoid  that 
came  under  his  observation;  and  the  bone  being  broken  longi- 
tudinally, and  the  accident  compound,  he  amputated  the  toot. 

In  the  case  of  Walker,  reported  in  The  Medical .Mtantiner, 
for  1851,  the  scaphoid  was  forced  forwards  and  upwards,  as  a 
stone  is  forced  from  an  arch.  By  bending  the  foot  downwards, 
the  surgeon  was  enabled  to  press  the  projecting  and  displaced 
bone  back  into  its  normal  position. 

Malgaigne  has  not  seen  a  case  of  dislocation  of  the  cuboid 
bone,  nor  has  he  confidence  in  the  reports  of  those  who  claim 
to  have  met  with  the  accident.  The  assertion  of  I'iodagnel, 


OF  THE  BONES  OF  THE  FOOT.  411 

that  the  bone  may  be  displaced  in  three  directions,  is  probably 
based  upon  speculation,  as  other  surgeons,  since  his  time,  have 
enjoyed  great  opportunities  for  observing  such  displacements, 
if  they  were  of  even  rare  occurrence,  and  no  well  authenti- 
cated accident  of  the  kind  has  been  reported.  There  seems 
to  be  nothing  in  the  shape  of  the  bone,  or  in  its  connections, 
to  prevent  displacement ;  and  that  is  probably  why  it  has  been 
stated  that  the  bone  may  be  dislocated  downwards,  inwards 
and  upwards. 

The  internal  cuneiform  bone  may- be  luxated  from  its  sca- 
phoid connection  in  an  upward  and  inward  direction,  as  if  in- 
riuenced  by  the  action  of  the  tibialis  anticus  muscle ;  and  its 
anterior  extremity  may  also  be  forced  from  its  metatarsal  rela- 
tions, though  in  conformity  with  the  nomenclature  adopted  in 
this  work,  such  a  displacement  must  be  considered  as  a  luxa- 
tion of  the  metatarsal  bones.  All  three  cuneiform  bones  have 
been  luxated  upwards,  the  deformity  being  marked,  and  the 
diagnosis  easy,  on  account  of  the  bones  being  thinly  covered 
on  the  dorsum  of  the  foot.  The  reduction,  when  the  internal 
cuneiform,  is  displaced  singly,  or  the  three  together,  is  not 
difficult.  The  foot  is  seized  in  such  a  way  that  the  hands 
bend  the1  anterior  part  of  the  foot  downwards,  and  the  thumbs 
press  the  bone  or  bones  back  into  place. 


DISLOCATION   OF  THE    METATARSAL    BONES. 

Robert  Wm.  Smith,  of  Dublin,  makes  the  following  appro- 
priate remarks :  "  When  we  reflect  upon  the  admirable 
mechanism  of  the  foot;  when  we  consider  the  beautiful  con- 
struction of  its  arches,  the  peculiar  forms  of  the  tarsal  bones, 
the  extent  of  their  articulating  surfaces,  and  their  mode  of 
adaptation  to  each  other;  when  we  also  take  into  account  the 
number  and  strength  of  the  ligaments  which  bind  them 
together,  the  arrangement  of  the  muscles,  tendons,  and  tendi- 
nous expansions  in  the  plantar  region,  and  the  very  slight  de- 
gree of  motion  which  is  permitted  to  the  bones ; — when  we 
reflect  upon  all  these  conditions,  we  find,  that  in  the  mechan- 
ism of  this  solid,  but  at  the  same  time,  highly  elastic  fabric, 
nature  has  adopted  every  provision  calculated  to  ensure 
strength,  and  immunity  from  external  violence. 


41 2  DISLOCATIONS. 

"  Notwithstanding,  however,  these  numerous  and  varied 
sources  of  security,  the  bones  of  the  foot  occasionally  suffer 
displacement,  when  subjected  to  the  influence  of  great  exter- 
nal force." 

Sir  Astley  Cooper  observes:  "The  metatarsal  bones  I  have 
never  known  luxated  ;  their  union  with  each  other,  and  irreg- 
ular connection  with  the  tarsus,  prevent  it;  and  if  it  ever  hap- 
pens, it  must  be  a  very  rare  occurrence." 

Mr.  Robert  Smith,  whose  words  have  just  been  quoted, 
twice  had  an  opportunity  of  ascertaining  by  post  mortem  ex- 
amination, that  the  metatarsus  and  internal  cuneiform  bone, 
were  dislocated  upwards  and  backwards,  the  luxations  having 
remained  unreduced  many  years.  The  appearance  of  the  foot 
in  both  instances  indicated  pretty  clearly  the  nature  of  the 
accident.  The  heel  preserved  its  natural  relations  to  the 
bones  of  the  leg;  but  the  foot  in  front  of  the  ankle-joint  was 
shortened  an  inch  or  more  ;  the  inner  edge  of  the  foot  was 
elevated,  and  the  outer  depressed  ;  the  sole  of  the  foot  exhibits 
a  rounded  appearance,  and  the  dorsum  a  transverse  promi- 
nence, situated  about  an  inch  below  and  in  front  of  the  ankle- 
joint.  Upon  examining  the  skeleton  of  the  foot,  the  meta- 
tarsal bones,  and  the  internal  cuneiform,  were  found  dislo- 
cated upwards  and  backwards  upon  the  tarsus.  The  accident 
which  effected  the  displacement  was  a  fall  from  a  horse. 

In  the  second  example  the  history  of  the  case  was  not  ascer- 
tained. The  patient  died  of  malignant  disease  of  the  abdomen 
at  the  Richmond  Hospital  ;  and  as  he  did  not  walk  lame,  no 
inquiry  was  made  concerning  the  condition  of  the  foot  wnich 
appeared  simply  fore-shortened  in  front  of  the  ankle-joint. 
The  appearance  of  the  foot  in  every  particular,  was  like  that 
of  the  other  just  described.  Dissection  showed  that  the  second. 
third,  fourth  and  fifth  metatarsal  bones,  and  the  internal 
cuneiform  bone,  were  dislocated  upwards  and  backwards  upon 
the  tarsus.  Anchylosis  had  taken  place  between  the  tarsus 
and  metatarsus,  and  osseous  buttresses  had  been  thrown  out 
to  assist  in  the  consolidation.  Mr.  Smith  thinks  the  disloca- 
tion is  liable  to  occur  "  when  a  person,  in  falling  or  leaping 
from  a  considerable  height,  alights  upon  the  anterior  part  of 
the  foot.  Under  these  circumstances,  the  limb  is  submitted 
to  the  operation  of  two  forces  operating  in  opposite  directions  ; 
one,  the,  weight  of  the  body  and  impulse  of  the  fall,  tending 


OF  THE  BOXES  OF  THE  FOOT.  413 

to  depress  the  tarsal  bones;  the  other,  the  resistance  of  the 
ground,  tending  to  displace  the  metatarsus  upwards  ;  the  ar- 
ticulating surfaces  thus  glide  past  each  other,  and  the  anterior 
part  of  the  foot  is  then  drawn  backwards,  and  the  aspects  of 
its  surfaces  altered  by  muscular  action." 

In  the  injuries  just  described  it  Avill  be  observed  that  the 
first  metatarsal  bone — the  one  to  which  the  great  toe  belongs — 
was  not  dislocated,  strictly  speaking,  but,  as  it  went  upwards 
and  backwards  it  followed  the  rest  of  the  metatarsal  row,  and 
the  internal  cuneiform  bone,  to  which  it  maintained  its  normal 
connections. 

Mr.  Smith  thinks  that  the  two  cases  of  dislocation  of  the 
metatarsus  upon  the  tarsus  related  by  Sanson,  as  having  hap- 
pened in  the  practice  of  Dupuytren,  may  have  been  strictly 
such,  but  he  inclines  to  the  opinion  that  the  internal  cuneiform 
bone  preserved  its  connections  with  the  first  metatarsal  bone  ; 
and  if  that  condition  was  overlooked,  he  regards  it  as  not  the 
slightest  disparagement  to  the  judgment  of  that  great  surgeon. 
The  two  cases  dissected  by  Smith  were  found  unreduced  ;  and 
it  is  not  known  whether  attempts  at  reduction  were  ever  made. 
Dupuytren  found  it.  impossible  to  reduce  the  bones  to  place  in 
the  two  cases  coming  under  his  treatment. 

In  a  case  of  dislocation  of  the  metatarsus  under  the  tarsus, 
reported  in  the  Dublin  Quarterly  Journal  of  Medicine,  1854,  as 
falling  to  the  practice  of  Mr.  Tufthell,  in  the  Dublin  City 
Hospital,  reduction  was  not  accomplished,  though  the  most 
powerful  and  persevering  efforts  were  made.  The  accident 
happened  to  a  trooper  whose  horse  fell  upon  the  soldier's  right 
leg  and  foot,  crushing  them  against  theground.  In  six  months 
after  the  accident  the  patient  was  able  to  walk  upon  the  heel 
and  outside  of  the  foot,  but  could  not  bear  any  weight  upon 
the  sole  on  account  of  the  burning,  lancinating  pain  excited 
by  the  endeavor. 

Dr.  Hershey,  of  Williamsville,  N.  Y.,  in  1856,  reported  to 
the  Boston  Medical  and  Surgical  Journal,  a  dislocation  of  the 
first,  second,  and  third  metatarsal  bones  upon  the  tarsus.  The 
accident  occurred  to  a  young  man  who  was  suddenly  dis- 
mounted from  a  horse.  The  reduction  was  accomplished  as 
follows :  an  assistant  made  counter-extension  upon  the  heel, 
and  the  surgeon  grasped  the  anterior  extremity  of  the  foot 
with  both  hands,  made  extension,  bent  the  toes  downwards, 


414  DISLOCATIONS. 

and  with  his  thumbs  pressed  the  projecting  bones  back  to 
their  natural  position. 

A  lateral  dislocation  of  the  metatarsal  bones  outwards  is  re- 
ported by  Dr.  Gross  to  have  occurred  in  the  practice  of  Drs. 
Green  and  Swift,  of  Easton,  Pa.  The  accident  happened  to 
an  elderly  gentleman  who,  in  falling  down  a  flight  of  stairs, 
sustained  the  injury.  The  metatarsal  bones  were  all  forced 
laterally  outwards  to  the  extent  of  a  half  inch  or  more  ;  and 
the  foot  is  reported  to  have  been  shortened  and  twisted. 

The  reduction  was  accomplished  by  extension,  and  pressure 
in  directions  calculated  to  return  the  displaced  bones  to  their 
natural  positions. 


DISLOCATION  OF  THE  PHALANGES  OF  THE  TOKS. 

The  great  toe  is  dislocated  at  the  metatarso-phalangeal  ar- 
ticulation much  more  frequently  than  the  other  toes.  Of 
twenty-two  cases,  confined  to  the  first  row  of  phalanges,  re- 
ported by  Malgaigne,  the  great  toe  suffered  luxation  in  nine- 
teen instances ;  and  in  the  three  other  cases,  all  the  toes  were 
dislocated  at  once.  The  displacements  are  generally,  if  not 
always,  upwards,  the  phalanges  being  forced  upon  the  meta- 
tarsal bones. 

Partial  displacements  of  the  toes  are  common  ;  and  com- 
pound luxations  are  more  frequent  than  in  displacements  at 
other  joints.  There  seems  to  be  a  certain  analogy  between 
the  dislocation  of  the  first  phalanx  of  the  great  toe,  and  that 
of  the  corresponding  phalanx  of  the  thumb;  and  a  similar 
difficulty  is  experienced  in  the  reduction.  As  both  joints  are 
organized  on  the  same  general  plan,  it  would  be  strange  if 
the  like  causes  did  not  produce  like  effects,  the  same  kind  of 
resistance  being  offered  in  both  articulations.  In  the  only 
case  of  dislocation  of  the  great  toe  at  its  metatarso-phalangeal 
articulation,  that  has  come  under  my  treatment,  1  met  with 
no  serious  obstacles  to  a  ready  reduction.  Extension  was 
made  upon  the  toe  by  an  assistant,  and  with  my  hands  around 
the  sides  of  the  foot  to  exert  counter-extension,  pressure  with 
the  thumbs  against  the  projecting  and  displaced  phalanx, 
effected  reduction.  In  the  event  of  failure  after  employing 
all  ordinary  means,  it  would  be  justifiable  to  divide  the 


Of   THE  BOXES   OF   THE   FOOT.  415 

ing  barriers,  whether  they  be  ligaments,  or  tendons,  or  both, 
though  such  a  course  should  be  avoided  if  possible. 

Dislocation  of  the  second  row  of  phalanges,  is  an  accident 
of  extremely  rare  occurrence.  Reduction,  by  means  of  exten- 
sion and  pressure,  has  not  been  difficult  in  the  few  oases  re- 
ported. 

The  terminal  bones  of  the  toes  have  been  luxated ;  and  the 
accident,  as  with  other  dislocations  of  the  toes,  generally 
arises  from  falls  received  in  horseback  exercise.  A  crushing 
force  so  directed  as  to  double  the  toes  under  the  foot,  is  the 
one  which  commonly  produces  displacement  of  one  or  more 
of  the  phalanges.  The  pain  attendant  upon  the  displacement 
is  severe ;  and  the  deformity  denotes  the  character  of  the  in- 
jury. Reduction  may  be  accomplished  by  the  ordinary  man- 
ipulation required  to  reduce  displaced  digital  extremities. 


INDEX. 


PART  1.  FRACTURES, 

PAGE 

Acromion  process,  fracture  of  the Ill 

Adhesive  strips,  for  making  extension 60 

Apparatus  for  treating  fractures 52 

Appliances,  defects  of,  in  fractures  of  the  femur 205 

adhesive  strip,  as  a  fastening  to  the  leg 230 

handkerchief,  as  a  fastening  to  the  lee:  ...  229 

o  o 

gaiter,  as  a  fastening  to  the  ankle 229 

Astragalus,  fracture  of  the 249 

Attitude  of  limb  in  treating  fractures  of  the  femur 193 

Bandages 52 

Brainard's  perforator,  for  treating  false-joint 39 

Burges'  fracture-bed 63 

Burges'  fracture  apparatus  for  treating  fractures  of  the  femur 200 

Calcaneum,  fracture  of  the 250 

Callus,  soft  and  yielding  after  apparent  consolidation 31 

provisional 32 

yielding  nature  of,  after  fractures  of  the  femur 201 

Capsule  of  hip-joint 179 

Carpus,  fractures  of  the 161 

Cartilages,  costal,  fracture  of  the 100 

laryngeal,  fr.-icture  of  the. 90 

Cervix  femoris,  fractures  of  the 172 

scapulae,  fracture  of  the 114 

Clavicle,  fracture  of  the 104 

Coccyx,  fracture  of  the 168 

Condyles  of  the  huruerus,  fractures  of  the 128 

of  the  femur,  fractures  of  the 211 

Convalescence 70 

Costal  cartilages,  fracture  of  the ,. -100 

Coracoid  process,  fracture  of  the 113 

Cranium,  fractures  of  the 74 

Crepitus  as  a  sign  of  fracture 24 

Dangerous  complications  in  fracture  injuries 25 

Defective  union  after  fractures 41 

Diastasis,  or  separation  of  epiphysis  of  the  humerus 125 

or  separation  of  epiphyses  in  general 72 

Differential  signs  of  fracture  and  dislocation 26 

Direct  and  indirect  forces  as  causes  of  fracture 21 

Direction  of  the  line  of  separation,  as  oblique,  transverse,  etc 19 

27 


418  INDEX. 

PACK. 

Dislocations,  (see  Part  Second) 2.v~i 

Division  and  subdivision  of  the  subject  of  fractures 18 

Dressings vj 

Dupuytren's  splint  and  fracture  dressing 246 

Epipbysis,  separation  of. 72 

Epiphysis  of  the  humerus,  separation  of  the 125 

Exercise  allowed  a  patient  treated  for  fracture 66 

Extension,  adhesive  strips  in  making.  60 

Fracture,  general  observations  upon  nature  and  treatment  of. 17 

division  and  subdivision  of  subjects  of,  as  simple,  compound,  partial. 

complete,  comminuted  and  complicated 18 

direction  of  the  line  of  separation  in,  as  oblique,  transverse,  etc 19 

comparative  frequency  of.  in  different  bones 20 

causes  of,  as  direct  and  indirect  violence 21 

signs  of,  as  pain,  mobility,  crepitus,  etc 22 

incomplete  or  "green-stick" , 26 

with  dangerous  complications 2.~> 

rendered  serious  by  railway  accidents,  etc 27 

apparatus ~ 5J 

beds ~ •'•- 

process  of  union  and  method  of  repair  in 2l,» 

non-union  after .. 36 

defective  union  after 41 

responsibility  in  the  treatment  of. 44 

management  of  compound .. 67 

of  the  cranium 74 

of  the  zygomatic  arch 74 

of  the  nasal  bones 75 

of  the  malar  bones  78 

of  the  superior  maxillary 78 

of  the  inferior  maxillary 80 

of  the  hyoid  bone » 88 

of  the  laryngeal  cartilages 90 

of  the  vertebrae 91 

of  the  ribs 95 

of  the  costal  cartilages 100 

of  the  sternum 101 

of  the  clavicle 104 

of  the  scapula 110 

of  the  acromion  process Ill 

of  the  coracoid  process M 113 

of  the  neck  of  the  scapula 114 

of  the  humerus.  117 

of  the  anatomical  neck  of  the  humerus...... 117 

of  the  tuberosities  of  the  humerus 119 

of  the  surgical  neck  of  the  humerus 120 

of  the  shaft  of  the  humerus 122 

of  the  humerus  just  above  the  condyles. !'.'.*> 

of  the  condyles  of  the  humerus : 128 

of  the  internal  condyle 129 

of  the  external  condyle 133 


INDEX.  419 

I'AGK. 

Fracture,  of  the  ulna  (olecranon  process) 137 

of  the  coronoid  process  of  the  ulna 140 

of  the  shaft  of  the  ulna 142 

of  the  radius 145 

of  the  shaft  of  the  radius 148 

of  the  radius,  (Colles7) 150 

of  the  radius,  (Barton's) 150 

of  the  carpus,  metacarpus  and  hand 161 

of  the  phalanges 163 

of  the  pelvic  bones,  as  ilium,  i&chium  and  pubes 165 

of  the  sacrum 167 

of  the  coccyx 168 

of  the  femur 171 

of  the  neck  of  the  femur 172 

of  the  cervix  femoris  within  the  capsule  (intra-capsular) 179 

of  the  neck  of  the  femur  outside  the  capsule  (extra-capsular) 180 

of  the  trochanter  major 185 

of  the  shaft  of  the  femur 190 

of  the  shaft  of  the  femur  just  below  the'trochanters 192 

of  the  shaft  of  the  femur  just  above  the  condyles 207 

of  the  condyles  of  the  femur 211 

of  the  patella 215 

of  both  bones  of  the  leg 221 

of  the  tibia,  singly 235 

of  the  fibula 240 

of  the  fibula,  Pott's ~ 242 

of  the  bones  of  the  foot 249 

of  the  astragalus 249 

of  the  os  calcis 250 

of  the  metatarsal  bones  251 

of  phalanges  of  the  toes 252 

femur,  fracture  of  the 171 

fracture  of  neck  of  th(5 172 

fracture  of  the  shaft  of  the  202 

fracture  of  the  condyles  of  the 211 

Fibula,  fractures  of  the 240 

Pott's  fracture  of  the 242 

and  tibia,  fracture  of  the 221 

Gaiter,  fastening  upon  the  ankle 229 

General  observations  upon  the  nature  and  treatment  of  fractures 17 

General  treatment  of  fractures 43 

Gibson's  apparatus  for  treating  fractures  of  the  thigh 206 

Gypsum  dressing 56 

Hand,  fractures  of  the 161 

Hamilton,  in  regard  to  mobility  at  seat  of  fracture 127 

Humerus,  separation  of  its  lower  epiphysis 73 

fracture  of  the 117 

fracture  of  the  anatomical  neck  of  the 117 

fracture  of  the  tuberosities  o' the 119 

fracture  of  the  surgical  neck  of  the 120 

fracture  of  the  shaft  of  the...  122 


420  INDEX. 

PAGE. 

Huntoon's  yoke-splint  for  treating  fracture  of  the  clavicle, 1<  8 

Hyoid  bone,  fracture  of  the 88 

Ilium,  fracture  of  the li;.~. 

Incomplete,  or  "green  stick"  fracture 'Hi 

Immovable  fracture  dressing .Vi 

Impaction  in  fractures  of  the  neck  of  the  femur 1  77 

Innominatum,  fracture  of  the 105 

Ischium,  fracture  of  the 165 

Jaw,  fractures  of  upper 78 

Jaw,  fractures  of  lower 80 

Laryngeal  cartilages,  fracture  of  the :in 

Levis' dressing  for  fracture  of  the  clavicle 1' 8 

Ligamentous  union  after  fracture  of  the  neck  of  the  femur 181 

Ligament,  capsular,  of  the  hip-joint 17H 

Ligamentous  union  after  fracture  of  the  patella Jl> 

Malar  bone,  fracture  of  the 7s 

Malgaigne  and  others  on  shortening  after  fracture  of  the  femur Hn:; 

Management  of  fractures 4?> 

Many-tailed  bandage ">;, 

Maxillary,  superior,  fracture  of  the 7o 

inferior,  fracture  of  the 

Metatarsus,  fracture  of  the 25 

Mobility  as  a  sign  of  fracture 'l'l 

"  Natural  method  "  of  producing  extension 48 

of  applying  extension  in  treating  fractures  of  the  femur 

Nasal  bones,  fracture  of  the ~\~< 

Neck  of  scapula,  fracture  of  the 114 

Neck  of  femur,  fracture  of  the 1  7  J 

Olecranon  process  of  ulna,  fracture  of  the l.:7 

Osseous  fragility -0 

Paget,  ensheathing  callus  of •"•  1 

Partial  fracture  (incomplete) 1M 

Patella,  fracture  of  the 215 

Pelvic  bones,  fracture  of  the IGo 

Phalanges  of  the  hand,  fracture  of  the It;:: 

of  the  foot,  fracture  of  the li.vj 

Pott's  fracture  of  the  fibula -J4M 

Pubes,  fracture  of  the ; 1U5 

Radius,  fracture  of  the '. 1  i."> 

fracture  of  the  neck  of  the 14." 

fracture  of  the  shaft  of  the 14* 

Colles'  fracture  of  the 150 

Barton's  fracture  of  the iSO 

Reduction  of  fractures 49 

Re-dressings  of  fractures 04 

Responsibility  in  the  treatment  of  fractures 44 

Ribs,  fracture  of  the !»"• 

Sacrum,  fracture  of  the H'.7 

Sand  bags  in  the  treatment  of  fractures  of  the  leg 47 

Scapula,  fracture  of  the 110 

Shoulder  blade,  fracture  of  the IK' 


INDEX.  421 

PAGE. 

Signs  of  fracture '.....  22 

differential,  of  fractures  and  dislocations -jfj 

silver  wire  to  fasten  together  fragments  of  lower  jaw 85 

Smith,  of  Dublin,  on  fracture  of  the  clavicle 105 

Spinal  cord,  injuries  of  the 92 

Splint,  long  straight,  for  treating  fractures  of  the  thigh 195 

Dupuytren's 246 

Starch  bandage,  treatment  of  a  case  with 234 

Sternum,  fracture  of  the » 101 

Swinburne's  method  of  making  extension 124 

Tarsal  bones,  fractures  of  the 249 

Tibia,  fracture  of,  singly 235 

Thigh  bone,  fracture  of  the 171 

Treatment,  of  fractures 43 

Trochanter,  fracture  of  the 185 

Ulna,  fracture  of  the  olecranon  process  of  the 137 

fracture  of  the  coronoid  process  of  the 140 

fracture  of  the  shaft  of  the 142 

Union  of  fractured  bones 29 

by  "first  intention." 33 

defective 41 

ligamentous,  after  fracture  of  the  neck  of  the  femur 181 

ligamentous  after  fracture  of  the  patella 218 

Weight  and  pulley  for  extension 199 

"  Wire  breeches  " 59 

in  the  treatment  of  fracture  of  the  neck  of  the  femur 188 

Zygomatic  arch,  fracture  of  the 74 


PART  II.    DISLOCATIONS. 


Ancient  dislocations,  dangers  in  attempts  at  reduction  of 271 

Ancient  dislocation  of  the  hip-joint 384 

Ankle,  dislocation  of  the 399 

Axillary  vessels,  dangers  of  rupture  of,  in  attempts  to  reduce  ancient  dis- 
locations of  the  shoulder 27:: 

Beach  on  the  reduction  of  dislocations  of  the  hip  by  manipulation 372 

Blackman  on  the  reduction  of  ancient  dislocations  of  the  shoulder 272 

Carpal  bones,  dislocation  of  the 352 

Carpus,  dislocation  of  the 349 

Cartilages  of  the  knee,  displacements  of  the 394 

Causes  of  dislocations 281 

Clavicle,  dislocation  of  the 305 

Dislocation,  general  consideration  of  the  subject 255 

an  injury  of  frequent  occurrence 255 

division  of  the  subject  of. 261 

congenital 261 


422  INDEX. 

PAGE 

Dislocation.',  traumatic 265 

partial 264 

ancient 265 

dangers  in  attempts  at  reduction  of. 271 

relative  frequency  of. 266 

symptoms  of 267 

alleged  malpractice  following 268 

recurring,  of  the  shoulder 277 

causes  of. 281 

general  treatment  of. 284 

compound 288 

of  the  inferior  maxillary 290 

of  the  vertebrae 297 

of  the  ribs 303 

of  the  clavicle 305 

of  the  scapula 310 

of  the  humerus 314 

of  the  shoulder , 314 

of  the  humerus,  with  fracture. 382 

of  the  elbow '•'>'•>•> 

of  the  head  of  the  radius  forwards 341 

of  the  head  of  the  radius  backwards 34* 

of  the  ulna  backwaras 346 

of  the  radius  from  thfi  ulna 347 

of  the  wrist 349 

of  the  carpal  bones 352 

of  the  metacarpal  bones  353 

of  the  phalanges  of  the  fingers 355 

of  the  thumb... 355 

of  the  fingers 357 

of  the  femur 359 

of  the  hip 359 

of  the  hip,  anomalous ~ 383 

of  the  hip,  ancient 384 

of  the  hip,  congenital 385 

of  the  hip,  partial 385 

of  the  hip,  and  fracture 38*5 

of  the  patella 388 

of  the  tibia 391 

of  the  knee 3',»L 

of  the  knee,  compound 396 

of  the  tibio-fibular  articulations 397 

of  the  fibula ::!»," 

of  the  ankle 3S>9 

of  the  bones  of  the  foot 4nr 

of  the  metatarsus 41  i 

of  the  phalanges  of  the  toes 4 1  4 

Elbow,  dislocation  of  the 'A'A't- 

Femur,  dislocation  of  the .:">'.< 

Fibula,  dislocation  of  the -''- 

Fingers,  dislocation  of  the  357 


INDEX.  423 

PAGE. 

Foot,  its  dislocation  outwards 399 

dislocation  of  the  bones  of  the 406 

Frequency  of  the  different  dislocations...... 266 

Gibson  on  the  reduction  of  ancient  dislocations 275 

Gilbe.'V?  substitute  for  the  pulley  force 369 

Hip,  dislocations  of  the 359 

dislocation  of  the,  with  fracture  of  the  femur , 386 

congenital  dislocation  of  the 385 

recurring  dislocation  of  the. 278 

Humerus,  dislocation  of  the 314 

with  fracture - 332 

ancient  dislocations  of  the 272 

Hysterical  affections  simulating  dislocations 284 

"  Indian  puzzle  " 358 

Jarvis  Adjuster 286 

Jaw,  dislocation  of  the 290 

Joints,  comparative  frequency  of  dislocations  at  the. 359 

Jones'  case  of  alleged  malpractice 268 

Knee-pan,  dislocation  of  the 388 

Knee,  dislocation  of  the 391 

displacement  of  the  semilunar  cartilages  of  the 394 

compound  dislocation  of  the 396 

Larkin  versus  Jones,  suit  for  alleged  malpractice 268,  317 

Ligaments  of  joints 258 

untorn  portions  of. 260 

Luxation,  see  Dislocation 255 

Malpractice — Larkin  versus  Jones 268,  317 

Markoe  on  the  reduction  of  dislocation  of  the  hip 374 

Manipulating  plan  for  reducing  dislocations  of  the  hip,  history  of  the 370 

Metacarpus,  dislocation  of  the 353 

Metatarsus,  dislocation  of  the 411 

"Natural  bone  setters" 255 

"  Natural  plan  "  of  reducing  dislocations  of  the  hip,  by  Reid 259 

Paralysis  following  dislocation  of  the  vertebrae 300 

Patella,  dislocation  of  the 388 

Pathology  of  dislocations 260 

Phalanges  of  the  fingers,  dislocation  of  the 355 

of  the  toes,  dislocation  of  the. 414 

Pulleys,  on  the  use  of,  in  reducing  dislocations 259,  3'is 

Pulley  force,  Gilbert's  substitute  for 369 

Radius,  dislocation  of  the 342 

from  the  ulna 347 

Reid's  manipulating  plan  of  reducing  dislocations  of  the  hip-joint....  259,  372 

Recurring  dislocation  of  the  hip 278 

Relative  frequency  of  dislocations 266 

Ribs,  dislocation  of  the 303 

Scapula,  dislocation  of  the 310 

Semilunar  cartilages  of  the  knee,  displacements  of  the 394 

Shoulder,  recurring  dislocation  of  the 277 

ancient  dislocations  of  the 27:! 

dislocation  of  the....  ..  314 


424  INDEX. 

PAGE. 

Spanish  windlass  for  multiplying  force '.'86 

Smith,  Dr.  Nathan t>r,»; 

Sweet,  "a  natural  bone  setter." 256 

Tarsal  bones,  dislocation  of  the 406 

Tarsus,  dislocation  of  the 399 

Tenotomy  to  facilitate  reduction  of  dislocations 288 

Tibia,  dislocation  of  the 319 

Tibio-fibular  dislocation 397 

Thumb,  dislocation  of  the 355 

Ulna  and  radius,  dislocation  of  the,  at  the  elbow 335 

dislocation  of  the,  backwards 346 

Vertebrae,  dislocation  of  the 297 

Warren  on  dislocation  of  the  hip 375 

Whitworth  "a  natural  bone  setter." 256 

Wrist,  dislocation  of  the 349 


COMPLETE 

DESCRIPTION  AND  PRICE  LIST 


OF 


MEDICAL  BOOKS 


PUBLISHED  AND  FOR  SALE 


JOHN  M.  SCUDDER, 

228  COURT  STREET,  CINCINNATI,  O. 

1888. 
Any  book  in  this  list  sent  post-paid  on  receipt  of  price. 


7T  S  a  school  of  medicine  we  profess  to  have  a  distinctive  practice,  unlike 
<§/i  either  our  old  school  or  homeopathic  neighbors.  We  claim  to  use  differ- 
ent remedies,  or  in  different  form  and  dose,  and  for  different  effects.  We 
boldly  claim  a  more  successful  practice  than  either  of  our  competitors,  and  this 
claim  can  only  be  based  upon  different  principles,  a  different  therapeutics,  and 
a  different  materia  medica. 

We  must,  therefore,  have  distinctive  books  which  clearly  state  our  methods 
of  practice.  Old-school  works  will  not  serve  this  purpose,  neither  will  homeo- 
pathic. With  the  pretensions  we  make,  if  we  can  not  show  that  we  have  such 
works,  and  depend  upon  them,  we  are  frauds  of  the  first  magnitude. 

In  the  early  days  of  Eclecticism,  the  need  of  text-books  was  clearly  seen, 
and  great  sacrifices  were  made  to  furnish  them.  The  writers  toiled  without 
pay,  and  to  publish  the  earlier  works  they  practiced  the  most  rigid  economy  for 
years  to  command  the  money.  By  these  means  we  had  Beach's  works,  Jones 
and  Morrow's  Practice,  King's  Dispensatory,  and  some  others.  The  making 
of  books  was  not  an  easy  nor  a  profitable  job. 

Now  we  have  a  full  list  of  text-books,  or  books  of  reference,  and  by  frequent 
revision  they  are  kept  fully  up  to  our  practice  of  to-day.  They  have  been  very 
successful,  more  so  than  any  American  books  in  the  market,  and  this  is  the  best 
evidence  of  their  value.  They  are  bought  by  all  schools  of 'medicine,  and  when 
bought  they  are  brought  into  active  use. 

—  1  — 


ECLECTIC  PRACTICE  OF  MEDICINE, 

BY  JOHN  M.  SCUDDER,  M.  D. 

The  best  recommendation  of  this  work  comes  in  the  statement,  "twelfth  edi- 
tion." It  is  the  authority  of  our  school  of  medicine,  and  thousands  of  sick  are 
daily  treated  according  to  it.  Thus  far  it  has  proven  sufficient,  and  it  has 
given  a  success  that  others  have  failed  to  obtain. 

Twelfth  edition,  revised :  8  mo.,  816  pp.,  Sheep ;  87.00  post-paid  ;  86.00  post-paid  to 
Journal  Subscribers. 

THE 

PRINCIPLES  OF  MEDICINE. 

BY  JOHN  M.  SCUDDER,  M.  D. 

This  is  a  study  of  the  elements  of  disease  and  the  principles  of  cure.  It  is 
the  basis  of  our  practice,  and,  as  we  think,  of  the  practice  of  the  future.  Jt 
gives  a  rational  basis  for  medical  practice. 

Fifth  edition  ;  8  mo.,  352  pp.,  Sheep ;  post-paid,  $4.00. 

mmW  PRACTISE  IN  DISEASES  OP  6H1LDREN. 

BY  JOHN  M.  SCUDDER,  M.  D. 

If  there  is  one  thing  more  than  another  that  we  take  pride  in,  it  is  our  suc- 
cess in  the  treatment  of  children.  The  teaching  of  pleasant  remedies,  in  small 
doses,  for  direct  effect,  has  relieved  thousands  of  children  from  the  horrors  of 
"regular"  medicine. 

Fifth  edition  ;  8  mo.,  486  pp.,  Sheep  ;  post-paid,  $5.00. 

A    PRACTICAL 

TREATISE  ON  THE  DISEASES  OF  WOMEN, 

ILLUSTRATED  BY 

COLORED  PLATES  AND  NUMEROUS  WOOD  ENGRAVINGS. 
BY  JOHN  M.  SCUDDER,  M.  D. 

WITH  A  PAPER  ON  THE  DISEASES  OF  THE  BRKAST,  BY  ROBERT  S.  NEWTON,  M.  D. 
Late  Professor  of  Surgery  in  the  Eclectic  Medical  Institute  of  Cincinnati. 

This  work  has  stood  the  test  of  twenty  years,  and  as  revised  it  gives  our 
treatment  of  to-day. 

Fourteenth  edition,  revised  ;  8  mo.,  534  pp.,  Sheep;  post-paid,  $4.00. 

Specific  Medication  and  Specific  Medicines 

BY  JOHN  M.  SCUDDER,  M.  D. 

Eleventh  edition,  fourth  revision  ;  12  mo.,  432  pp.,  Cloth  ;  Price.  $2.50. 


SPECIFIC  DIAGNOSIS. 

BY  JOHN  M.  SCUDDER,  M.  D. 

Seventh  edition ;  12  mo.,  388  pp.,  Cloth ;  Price,  82.50. 

These  companion  volumes  have  had  a  larger  sale  than  any  other  medical 
works  in  this  country.  They  appeal  to  the  feeling  every  thinking  physician 
cherishes  that  there  must  be  something  certain  in  medicine,  if  it  can  be  dis- 
covered. They  have  had  a  very  marked  influence  upon  medical  practice,  not 
only  of  our  own  school,  but  also  on  regular  medicine  and  homeopathy. 

9 


THE  AMERICAN   ECLECTIC 

MATERIA  MEDICA  AND  THERAPEUTICS, 

BY  JOHN  M.  SCUDDER,  M.  D. 

Tenth  edition  :  8  mo.,  748  pp.,  Sheep:  post-paid,  86.00. 


BY  JOHN  M.  SCUDDER,  M.  D. 

Twenty-first  edition ;  Cloth,  $300;  Sheep,  $4.00;  half  Morocco,  $5.00. 

This  work  contains  all  of  medicine  that  a  family  should  know.  It  is  anato- 
my, physiology,  hygiene,  practice,  materia  medica,  surgery,  and  obstetrics.  It  is 
concise,  plain  and  correct,  and  will  not  lead  to  household  drugging.  Liberal 
offers  to  agents.  Write  for  terms. 

* , . . — _ 

ON    THE 

REPRODUCTIVE  ORGANS]™^  VENEREAL 

BY  JOHN  M.  SCUDDER,  M.  D. 
WITH  COLORED  ILLUSTRATIONS  OF  SYPHILIS. 

Second  edition  ;  8  mo.,  393  pp.,  Sheep;  post-paid,  $5.00. 

OUR  PROF.  JOHN  KING,  WHO  HAS  BEEN  A  TEACHER  FOR  NEARLY  HALF  A 

CENTURY,  IS  TOO  WELL  KNOWN  TO  REQUIRE    MORE    THAN  A 
CATALOGUE  OF  HIS  BOOKS.     THEY  ARE  AS  FOLLOWS  : 


THE   AMERICAN   DISPENSATORY. 

WITH  SUPPLEMENT  BY  J.  U.  LLOYD. 
Tenth  edition  ;  Sheep  ;  Price,  810.00. 


DIAGNOSIS  and  TREATMENT  of  gMRONIg  DISEASES 

1700  pages :  Sheep  ;  Price,  810.00. 

THE  AMERICAN  ECLECTIC  OBSTETRICS. 

Fourth  edition  :  Sheep ;  Price,  S6.50. 

WOMAN,  HER  DISEASES  AND  THEIR  TREATMENT 

Fourth  edition  ;  Sheep :  Price.  $3.50. 

UROLOGICAL  DICTIONARY. 


Sheep :  Price,  S3.00. 
—3— 


PROF.  HOWE  is  RECOGNIZED  AS  ONE  OF  THE  ABLEST  TEACHERS  IN  THIS 

COUNTRY,  AND  AN  OPERATING  SURGEON  WITH  BUT  FEW  PEERS  IN  THE  WEST. 


ART  AND  SCIENCE  OF  SURGERY. 

Revised  edition  ;  8  mo.,  886  pp.,  Sheep  ;  Price,  $7.00. 

Diagnosis  and  Treatment  of  Dislocations  and  Fractures 


Third  edition ;  426  pp.,  Sheep ;  Price,  $4.00. 


MANUAL  OF  EYE  SURGERY. 


8  mo.,  204  pp.,  Cloth;  Price,  82.50. 


THE  CHEMISTRY  OF   MEDICINES. 

PRACTICAL. 

A  text  and  reference  book  for  the  use  of  students,  physicians,  and  pharma- 
cists. Embodying  the  principles  of  chemical  philosophy,  and  their  application 
to  those  chemicals  that  are  used  in  medicine  and  in  pharmacy,  including  all  those 
that  are  officinal  in  the  Pharmacopoeia  of  the  United  States.  With  fifty  original 
cuts.  By  J.  TJ.  LLOYD,  Professor  of  Chemistry  and  Pharmacy  in  the  Eclectic 
Medical  Institute,  Cincinnati,  O. ;  corresponding  member  of  the  College  of 
Pharmacy  of  the  City  of  New  York ;  associate  author  of  the  Supplement  to  the 
American  Dispensatory ;  author  of  the  Pharmacy  and  Chemistry  of  the  Student's 
Pocket  Medical  Lexicon. 

One  volume;  large  12  mo.,  451  pp. :  Cloth,  82.75;  Leather,  83.25. 

'  OTHER  BOOKS  NOT  PREVIOUSLY  MENTIONED, 


ON  INHALATIONS.    John  M.  Scudder.    Cloth SI  00 

PATHOLOGICAL  ANATOMY.    J.  A.  Jeancon.    25  parts, 

$1.00  per  part,  or  bound  complete,  Cloth 30  00 

GRAY'S  ANATOMY.     Sheep,  7.00;  with  Colored  Plates,  8  25 

HOLDEN'S  ANATOMY.     Oil-cloth 4  50 

DUNGLISON'S  DICTIONARY.     Sheep 7  50 

THOMAS'  MEDICAL  DICTIONARY.   Cloth,  $5.00;  Sh'p,  6  00 

HUXLEY  AND  YOUMAN'S  PHYSIOLOGY.    Cloth...  1  60 

CLEVELAND'S  LEXICON Cloth,  81.00;  Leather,  1  25 

STEELE'S  PHYSICS 1  17 

TENNY'S  NATURAL  HISTORY 1  38 

HUXLEY  &  YOUMAN'S  BIOLOGY 1  50 

BASTIN'S  BOTANY 2  50 

FOSTER'S  PHYSIOLOGY Cloth,  $3.25 ;  Sheep,  3  75 

PITZER  ON  ELECTRICITY 1  00 

MERRILL'S  MATERIA   MEDICA 400 

CLARK'S  DISEASES  OF  WOMEN.     Sheep 4  00 

Any  other  medical  book,  not  enumerated  in  this  list,  sent  post-paid  on 
receipt  of  publisher's  price.  J.  M.  SCUDDER, 

CINCINNATI,  O. 

-4— 


Date  Due 


PRINTED    IN    U.S.A.  CAT.      NO.      24 


A  000  499  522 


WE175 
H855p 

1891 
Howe,  A        J 

Practical  and  systematic  treatise 
fractures  and  dislocations 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


